HPV Info

HPV Info

FAQ

What is HPV?

HPV is a virus contracted through skin-to-skin sexual contact, is very infectious, and is spread via sexual activity.

What is the definition of being sexually active?

The definition of sexual activity: The minute you go below the belt with fingers, mouth, or other body parts – even without penetration.

Do condoms prevent HPV?

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 sexual contact.

How predominant is HPV?

3 out of 4 sexually active people will contract one form or another of HPV in their lifetime.

Which cancers are caused by HPV?

  • Tonsil and vocal chords
  • Tongue
  • Throat
  • Anus
  • Cervix
  • Vulva
  • Vagina
  • Penis

What causes genital warts?

HPV causes 100% of genital warts cases.

If I have HPV, can I transmit it to my parter and then be reinfected?

It’s possible. If your partner is HPV positive.

What is HPV?

The letters H P V stand for the Human PapillomaVirus. This virus has over 180 different strains that are numbered, HPV 1, HPV 2, and so on. 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 do not fully protect people from giving/getting this virus because the condom only covers the length of the penis; there are still other parts below the waist that will have direct skin-to-skin contact.

This certainly includes inserting a penis or an object into a vagina or anus, as well as rubbing skin-to-skin against each other below the waistline without any penetration. This type of touching puts people in direct contact with this virus due to the skin-to-skin touching and exchange of bodily fluids (pre-cum and semen that comes from a penis each time a male ejaculates and vaginal discharge from a female). Unfortunately, there typically are no signs or symptoms of this virus for either partner, regardless of sex or gender.

“A person can contract HPV simply through sexual contact between the genitals and the fingers, mouth, or other body parts… even without penetration.”

This virus could appear as genital warts or lead to certain cancers. Genital warts can be found anywhere from the waist down to the knees, at the front and back of a person’s body. Genital warts are small, raised, hard lumps that grow in clumps. They are usually painless but may cause itching, burning, or light bleeding. This virus can manifest itself as genital warts and spread below the waistline through any skin-to-skin sexual contact.

There are also some strains of this virus that can lead to cancers of the head, neck, throat, tongue, cervix, vagina, anus, and penis. It can be asleep in a person’s body for up to 30 years. This means what we do in our teens, 20s, 30s, or 40s can affect us in our 50s, 60s, 70s, and 80s simply because it can take up to 30 years before developing symptoms. It is clear that HPV is highly contagious. The good news is that there are preventative methods. I strongly recommend that you and any partner be protected from this virus with the HPV vaccine. Your health care provider can give you more information about a vaccine called Gardasil 9. It is given in 3 doses over a 6-month period.

Human Papillomavirus (HPV) is an extremely common virus. At some point in our life, most of us will catch the virus. The world over, HPV is the most widespread sexually transmitted virus; 80% (four out of five) of the world’s population will contract some type of the virus once 1. If you catch HPV, in the majority of cases, the body’s immune system will clear or get rid of the virus without the need for further treatment. In fact, you may not even know that you had contracted it.

There are over 100 identified types of HPV; each different type has been assigned a number. HPV infects the skin and mucosa (any moist membranes such as the lining of the mouth and throat, the cervix, and the anus). Different types affect different parts of the body causing lesions. The majority of HPV types infect the skin on external areas of the body including the hands and feet. For example, HPV types 1 and 2 cause verrucas on the feet 2.

Around 40 of the HPV types affect the genital areas of men and women, including the skin of the penis, vulva (area outside the vagina), anus, and the linings of the vagina, cervix, and rectum 3. Around 20 of these types are thought to be associated with the development of cancer. The WHO International Association for Research on Cancer (IARC) identifies 13 of these types as oncogenic (cancer-causing). This means there is direct evidence that they are associated with the development of cervical cancer and are considered high-risk 4. These high risk types of HPV are: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68 5. A person infected with high-risk HPV will show no symptoms so they may never even know they have it.

Additionally, there are nine HPV types that may also be associated with the development of cervical cancer these are types: 26, 53, 64, 65, 66, 67, 69, 70, 73, 82. However, currently, there is not enough evidence to indicate that these types are at high risk for cervical cancer 6.

The remaining HPV types have been designated low-risk as they do not cause cervical cancer but they can cause other problems such as genital warts.

Signs and Symptoms

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How do I get HPV?

A person can contract HPV simply through sexual contact between the genitals and the fingers, mouth, or other body parts… even without penetration.

Anybody who has ever been sexually active is at risk of contracting HPV. People come into contact with this virus, through any skin-to-skin sexual contact below the waistline with fingers, mouths, or other body parts, including genital-to-genital contact, anal intercourse, and oral sex… 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.

The time from exposure to the virus to the development of warts or cervical disease is highly variable and the virus can remain dormant in some people for long periods of time. Often it is not possible to determine exactly when or from whom the infection originated.

High-risk HPV infections are very common and infected individuals will have no symptoms, therefore, it is very difficult to tell whether an individual is infected. There is no treatment for a high-risk HPV infection. Usually, the body’s own immune system will clear the infection. Practicing safe sex through the use of condoms can help reduce the risk of being infected with HPV but it will not completely eradicate the risk as HPV lives on the skin in and around the whole genital area 7

HPV Testing

Females thirty years old and over can find out for certain if they have a high-risk strain of this virus by getting an HPV test. It is performed like a pap smear, there is approximately a $100 fee for the HPV test and you get the results typically within two weeks. You must request the HPV test from your health care provider as this is not a routine test. There are many strains of the virus, and as said earlier here some strains of this virus lead to cancers such as cervical cancer. I would recommend all females over thirty years old and over get an HPV test instead of a pap smear because it is more accurate.

There is no test that exists to know if a male has HPV. The only way a male can know if he has this virus is when treating the symptoms of this virus that may come out as genital warts or HPV-related cancer such as head, neck, throat, tongue, anal or penile cancer. We can assume that if one person in the relationship has HPV, probably the other person has it too because of how easy it is to come into contact with.

There is no treatment for an HPV infection as usually the body’s own immune system will clear the infection. However, a persistent HPV infection with a high-risk type may lead to cervical abnormalities and increase the risk of developing cervical cancer. The results of an HPV test combined with cervical screening cytology (examination of the cells under a microscope) enable faster investigation of those at higher risk of developing cervical cancer, and reassurance of those at very low risk. The test can also reduce the number of unnecessary screening appointments and colposcopies among women with borderline or mild cervical screening cytology results or who have been treated for abnormal cells. If you are interested in getting an HPV test, ask your doctor about getting one with your next Pap test.

The HPV test is carried out using the same sample of cells taken during a cervical screening test. In the laboratory, the cells are analyzed for current HPV infection.

For more details on HPV facts, please view HPV FACTS in the right column.

You can also order an at-home HPV test through Eve kit: https://evekit.com/shop/

The Cervix

The cervix (or neck of the uterus) is the lower, narrow part of the uterus which connects to the top end of the vagina. The opening of the cervix is called the os. The cervical os allows menstrual blood to flow out from the vagina during menstruation. During pregnancy, the cervical os closes to help keep the fetus in the uterus until birth. During labor, the cervix dilates – or widens – to allow the passage of the baby from the uterus to the vagina. Approximately half the cervix length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view.

The cervix is covered with a layer of skin-like cells on its outer surface, called the ‘ectocervix’. There are also glandular cells lining the inside of the cervix called the endocervix; these cells produce mucus. The skin-like cells of the ectocervix can become cancerous, leading to squamous cell cervical cancer. As well, the glandular cells of the endocervix can become cancerous, leading to adenocarcinoma of the cervix.

The ectocervix and endocervix have three main skin layers or zones:

The Basal Layer—cells are produced here. Older cells are pushed up towards the surface. If you contract HPV, the virus will attack the basal layer cell.
Midzone—the middle layer of cells. As cells move up from the basal layer they lose their capacity to divide making them fully mature cells.
Superficial Zone—The uppermost surface of the cervix where mature cells eventually die and shed in the normal process of skin shedding 8. The cervical screening takes cells from this area.

The area where cervical cells are most likely to become cancerous is called the transformation zone. This is the area just around the opening of the cervix that leads on to the endocervical canal (the narrow passageway that runs up from the cervix into the womb). The transformation zone is the area that your doctor or nurse will concentrate on during cervical screening.

The vagina is the tube extending from the outside of the body to the entrance to the womb. The skin-like cells that cover the cervix join with the skin covering the inside of the vagina; so, even if you have had your womb and cervix removed, you can still have screening samples taken from the top of the vagina.

CERVICAL SCREENING

Cervical screening is NOT a test to find cancer. It is a screening test to detect abnormalities (pre-cancer) at an early stage in the cells of the cervix.

Cervical screening is the process of taking a sample of cells from your cervix, which are then examined to detect abnormalities that could develop into cancer in the future. The sample of cells is placed in a liquid so that it can be analyzed in the laboratory. This process is called Liquid-Based Cytology (LBC). Screening can detect precancerous/abnormal cells. The detection and successful treatment of these cells usually prevent the occurrence of cancer. Changes in these cells are generally caused by certain types of human papillomavirus (HPV). Testing for the HPV virus itself can also be done on the same LBC sample that is examined under the microscope. For more information on HPV testing click here.

Around 1,408 new cervical cancer cases are diagnosed annually in Canada 9. Regular cervical screening provides a high degree of protection against developing cervical cancer. Not receiving cervical screening is one of the biggest risk factors for developing cervical cancer.

Those with Compromised Immune Systems

Women who have a severely compromised immune system such as HIV may need to be screened annually as they are more likely to develop a persistent infection of HPV which can over time cause cervical abnormalities. Women who are HIV positive will need to attend screening every year, the screening test is usually taken outside of the National Screening program. Men with a severely compromised immune system are also at higher risk of contracting HPV. Please check with your health care professional for further information on screening and vaccination.

Not Eligible for Cervical Screening – Under 25

Each year in Canada, approximately 1,408 are diagnosed with cervical cancer. Cervical cancer is the 3rd most common female cancer for women aged between 14 and 44 years old in Canada 10. The number of young women diagnosed will be reducing over the next ten years due to the HPV vaccination program which offers the vaccine to girls under 18 years of age. This program was introduced in 2008 and will help to prevent the majority of cervical cancers 11.

Those young women who are diagnosed with cervical cancer under the age of 25 often experience typical symptoms prior to diagnosis.

Symptoms of cervical cancer

The most common symptom is Abnormal vaginal bleeding, in between periods, during or after sex.

Other symptoms include:

  • Unusual and/or unpleasant vaginal discharge,
  • Discomfort or pain during sex
  • Lower back pain.

Abnormal vaginal bleeding is quite common and is not usually serious. If a woman is experiencing symptoms such as abnormal bleeding she does not require a cervical screening test but will need to be examined by her GP and should undergo a direct examination of the cervix in order to rule out the very small chance that a cancer is present.

Vaginal bleeding is extremely common and can be caused by a range of different problems including changes to the cervix (neck of the womb) called ectropion or cervical erosion, changes in hormones due to the contraceptive pill or benign cervical polyps or a sexually transmitted infection such as Chlamydia. The guidelines explain to GPs the types of questions they need to ask to establish if the symptoms could be related to cervical cancer. A pelvic exam can be done by a GP.

If you are experiencing any of these symptoms or are concerned about any new symptom it is important that you make an appointment to see your GP as soon as possible. Some women find it embarrassing to talk about gynecological problems. If you feel like this, you are not alone. In a recent survey, 80% of women said they would see a doctor for a cold that lasted more than 3 weeks, compared to only 50% if they bled outside of a period [3]. However, your GP will not be embarrassed and they are used to talking about these subjects. Because abnormal bleeding can be a symptom of cervical cancer it is vital you seek some advice from your GP. If you want to you can also take a relative or a friend with you who can support you during your appointment with the GP.

You might also find it helpful to take the Department of Health guidance along with you to discuss with your GP.

Why does cervical screening start at 25?

According to the most recent research, abnormal cervical cells are caused by high-risk infection with HPV and are very common in women under 25. They are less common in older women.

A high-risk HPV infection has no symptoms so most women will be infected and not even know. Whilst a woman has high-risk HPV, the infection can cause cells of the cervix to become abnormal (these abnormalities are sometimes called pre-cancerous changes). For most women, these cervical abnormalities will clear up by themselves as the body’s own immune system gets rid of the HPV infection 12. Some women are unable to clear high-risk HPV and the abnormal cervical cells caused by this infection could with time turn into cervical cancer.

Because high-risk HPV infections are common in young women, screening young women means that there would be a high number of women receiving a positive result indicating that they have abnormal cervical cells that would require further investigation. Most women with high-risk HPV will clear the infection within 12 to 18 months and then the cervical abnormalities will go back to normal. But medical experts do not currently have a way to understand which women will be able to clear their abnormalities and which could go on to have cancer. However, they do know that if a woman is older than 25 and abnormal cells have not cleared up on their own, there is a greater need to offer treatment.

So if young women are more likely to have abnormal cells this means these women will be more likely to be sent for treatment to remove the abnormal cells following a screening test.

Treatment for cervical abnormalities has been shown to increase the risk of preterm labor and cause unnecessary anxiety for the woman. 13 14 15 16

Diagnosis and treatment for cervical abnormalities have been shown to cause significant psychological trauma and, considering the majority of young women will clear these abnormalities without treatment, it means screening and subsequent treatment for abnormalities could cause more harm than the benefits of screening can provide.

Additionally, cervical screening has been shown not to be very effective in young women. In countries where screening started at 20, rates of cervical cancer in women under 25 are not significantly different to countries that start screening at 25 17.

The International Agency for Research on Cancer also recommends that women should not start cervical screening before the age of 25.

Summary

  1. Cervical cancer is very rare in women under 25.
  2. Abnormal vaginal bleeding can be a symptom of cervical cancer – there are guidelines in place for the under 25s with abnormal bleeding. You should see your GP if you are bleeding outside of your period or after sex.
  3. Cervical screening (the smear test) is not recommended for women under 25.

What will happen during my Cervical Screening?

Having your cervical screening sample taken should only take a matter of 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 GP 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.

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 GP/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 GP/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 GP/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 the microscope in the laboratory.

In the laboratory, the contents of the vial are spun and treated to remove obscuring material.

For most women, cervical screening is not painful but it may feel a little uncomfortable, therefore, if you experience any pain or other problems please do 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 to be taken 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 GP surgeries will ask you to book the test so do take your menstrual cycle into account before your book your screening test.

Helpful tips before your cervical screening

For many women, the thought of going for cervical screening is often worse than the reality. Do not worry if you feel anxious about having your screening test, this is normal and many women 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 GP 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.

Colposcopy

Tests Done at Colposcopy

There are two different techniques used to identify abnormal cell changes during the colposcopic examination:

Acetic Acid Colposcopy

Acetic acid (dilute vinegar) is applied to the cervix using a cotton wool ball or by a spray. Abnormal areas such as CIN will tend to turn white (acetowhite). It is important to say that some areas of acetowhite do not indicate CIN at all. One of the challenges facing the colposcopist is to decide which areas of acetowhite truly represent areas of abnormal cells that need to be removed so that over treatment is avoided.

Schiller’s Iodine Test

The colposcopist may use another test using an iodine solution. Normal tissue on the outside of the cervix stains dark brown when iodine is applied. On the other hand, cervical abnormalities may not stain with iodine. This test may be used following acetic acid colposcopy and is often used before treatment.

Diagnosis

Most colposcopists use a combination of the acetic acid and Schiller’s iodine tests. 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 goes after using acetic acid
  • How quickly the tissue turns white
  • How smooth or irregular the surface is

The different patterns of the blood vessels (mosaic and punctation) under the surface of the cervix.

Taking a Biopsy

To be sure of the diagnosis, a biopsy is often required – this means taking a sample of tissue from the cervix. Depending on the results of this biopsy the colposcopist will decide whether you need treatment. There are 2 types of biopsy 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. 

Treatment options will be outlined to you in your information leaflet before your clinic appointment and will be discussed with you in clinic. 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. If necessary the colposcopy can be stopped.

Results of Biopsy

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

  • The cell nucleus – irregular size, shape and colour of the cell nucleus is the first indication of an abnormality.
  • The maturity of the cells – a normal cell will grow from an immature to mature cell. Cells that are abnormal can often still grow into mature cervical cells which still function in a similar way to normal cells. If the abnormal cells still mature this indicates a low grade abnormality (e.g. CIN 1). New cells that grow with increased abnormalities may no longer be able to function normally and may remain as immature abnormal cells. The more immature the abnormal cells there are the higher the grade of abnormality (e.g. CIN2 and 3). Immature abnormal cells have greater potential to develop into cancerous cells than mature abnormal cells.
  • The thickness of abnormal cells in the lining of the cervix – the grading for CIN cells comes from the thickness of immature abnormal cells within the ectocervix.

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

  • If you have CIN 1 the lining of the cervix has fully normal cells at the surface and the lower 1/3 has immature abnormal cells.
  • CIN 2: the lining of the cervix has norrmal cells at the surface and the lower 2/3 has abnormal cells.
  • CIN 3: the lining of the cervix has abnormal cells throughout it’s 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 called the ectocervix. There are also glandular cells usually lining the inside of the cervix called the endocervix. These cells produce mucus. The skin-like cells of the ectocervix can become cancerous, leading to a squamous cell cervical cancer. The glandular cells of the endocervix can also become cancerous, leading to an adenocarcinoma of the cervix. Changes to these different areas are categorised differently: Cervical Intraepithelial Neoplasia (CIN) are cellular changes to the ectocervix and Glandular Cervical Intraepithelial Neoplasia (CGIN) represent abnormal changes to the endocervix. 

Treatment for CIN depends on the degree of abnormality of the cells. CGIN is not as common as CIN, but it is treated similarly. There is no good evidence that CGIN is “more aggressive” than CIN. CGIN is harder to pick up during screening and since the cellular changes are inside the cervical canal they can be marginally more difficult to treat. 

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, if untreated lead to cancer but CIN and CGIN are not in themselves cancerous. Treatment for abnormal cellular changes is usually very successful.

Abnormal cells and treatment

Abnormal Cervical Cells and Treatment

The cervix is covered with a layer of skin-like cells on its outer surface, called the ectocervix. The results of your cervical screening test are based on the examination of the cells from the surface of the ectocervix. The test detects whether abnormal cells are present.

Cells that are found in the cervical canal are called endocervical cells (glandular cells); these are different from the ectocervix. The transformation zone is the area from where the endocervix meets the ectocervix. This is where glandular cells normally change to squamous cells of the ectocervix. Rarely, some women have endocervix cells that are 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 analyse the cells from the layer beneath the surface, this is called a biopsy. Usually biopsies are only a few millimetres in size. During the colposcopy the doctor or nurse will explain the procedure to you further. In this section we will explain more about colposcopy and give you information on possible treatment for cervical abnormalities.

How it Feels to Have Cervical Abnormalities

Every year, almost 400,000 Canadian women receive a call that their Pap test result is abnormal (http://www.paptestinfo.ca/index_e.html). 

Following a diagnosis of cervical abnormalities (and you have been offered treatment) women can feel a range of different emotions and this is perfectly normal. It is quite common for women to question why this has happened to them and whether or not it could have been prevented. Some women feel angry that the abnormal cells weren’t detected earlier or find it difficult to digest a diagnosis of HPV alongside this. 

Whilst many women feel absolutely fine and aren’t unduly concerned, some might feel anxious, scared and overwhelmed, and some worry about what will happen 118. It is common for emotions to rollercoaster – with you feeling calm and untroubled one day, but scared or angry the next. 

Women in Jo’s Cervical Cancer Trust’s community tell us that their feelings often change over time, as they gradually learn more about what having cervical abnormalities actually means for them. As you will see in the Your feelings may change over time section, 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 find more here. You can also submit questions online to a medical professional through our Ask the Expert service. 

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 GP. We provide the following service which enables you to speak to someone safely and confidentially:

  • You can use our online forums to connect with women who are going through, or have been through, similar experiences.

Your Feelings May Change Over Time

Most women gradually find ways that help them deal with what’s happening to them, and their feelings about their diagnosis changes over time 118

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

Many women find that being better informed, for example understanding what the treatment procedures will be and what the benefits and possible side effects could be, helps them regain control of their situation and reduces their anxiety. 

Some women 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.

Advice and Tips from Other Women

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 chat to friends and work 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 abnormal (http://www.paptestinfo.ca/index_e.html). 

Many women find it helps to talk about their 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 chat to women who have been through the same procedures, or even read about their experiences online or take a look at some of other women’s stories, it may help reduce your anxiety about what lies ahead. Women often use our online forum for this purpose. 

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 Awareness Corporation, 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 you developing cancer in the future.

HPV Triages

HPV Triage is used when a woman has a cervical screening result of borderline or mild dyskaryosis (or low grade squamous dyskaryosis). The HPV test is important because it allows earlier identification of women who need treatment. Women with minor cervical abnormalities (either borderline or low grade squamous dyskaryosis) have only around a 15-20% chance of having a significant abnormality that requires treatment 1

If a woman does not have high risk HPV even though her screening result showed slightly abnormal cells, the risk of these abnormalities turning into cancer are extremely low, thus, the woman can return to normal routine screening. 

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 the woman will be invited to attend a colposcopy clinic. If the test is HPV negative the woman will be returned to routine screening every three or five years depending on her age and the country she lives in.

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 at a first visit to Colposcopy. 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 (the grade of CIN and/or the presence of CGIN) and how advanced the changes are. Your colposcopist will advise you on the specific treatment you will require during your colposcopy appointment. CIN1 is usually not treated as these changes often return to normal given time and are not precancerous.

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 in theatre while you are under anaesthetic. This is like a long bandage that puts pressure on the biopsy site and so helps stop any bleeding (a bit like putting pressure on a cut to stop it bleeding). It will be removed before you go home. It is advisable to have some painkillers at home (such as you would take for period pains) as some women experience a deep ache and/or tenderness in their 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 like the end of a period for two to three weeks after your treatment. However this does vary a lot, for example a few women 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 that you can have during your period. 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 GP 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). You might need some pain relief after your treatment, the clinic where you had treatment can advise you on this. 

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

After Your Treatment

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 – this will usually be done at your GP surgery. Between 5-10% of women continue to have cervical abnormalities after treatment. Occasionally second and third treatments are required. It is highly important that you attend treatment if further treatment is advised.

Test of Cure

These follow up tests help to identify 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 women who 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). Test of cure is done if the abnormality treated was CIN rather than CGIN. 

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. You do not need to have another cervical screening test for three or five years depending on your age or upon your country’s screening programme. 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 please 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 too stick a bit back on! If there are still abnormal cells left at follow up, then a further 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 women 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 really 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.

Cervical Cancer

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. 123

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 four out of five people are exposed to the virus. Anyone who is sexually active can be infected with HPV at some time and the body’s immune system will usually clear it up. Generally, most people don’t even know they have contracted the virus.

Cervical abnormalities are caused by persistent high-risk HPV infection. These abnormal cells found through cervical screening are not cancerous but, given time (often years), they may go on to develop into cancer. However, the cells often return to normal by themselves.

The most effective method of preventing cervical cancer is through regular cervical screening which allows for the detection of any early changes of the cervix. For younger women, the HPV vaccination can help prevent seven out of ten cervical cancers (70%). Cervical cancer is largely preventable and, if caught early, survival rates are high.

Causes of Cervical Cancer

Almost all cases of cervical cancer are caused by persistent high risk HPV. HPV is a very common infection that four out of five sexually active adults will come into contact with in their lives, without any symptoms. This is why it is so important 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 these are called high risk types. Whilst these factors are considered to increase your risk of developing cervical cancer, many women who have only had one sexual partner in their lifetime become infected with high risk HPV and may go on to develop abnormal cell changes/CIN or cervical cancer. 

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 the 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.

Symptoms of Cervical Cancer

There are usually no symptoms with abnormal cervical cells and sometimes there are no symptoms with early stage cervical cancer. However, there are some recognised symptoms associated with cervical cancer. These include;

  • Abnormal bleeding: during or after sexual intercourse, or between periods
  • Post menopausal bleeding, if you are not on HRT or have stopped it for six weeks
  • Unusual and/or unpleasant vaginal discharge
  • Discomfort or pain during sex
  • Lower back pain.

If you are experiencing any or all of these symptoms or are concerned about any new symptom you should make an appointment to see your GP as soon as possible. Remember, these symptoms can be associated with many other conditions that are not cancer related. 

Not all women diagnosed with cervical cancer experienced symptoms this means attending regular cervical screening is even more important. As cancer develops, it can cause further symptoms;

  • Frequency of urine
  • Blood in the urine
  • Rectal bleeding
  • Diarrhea
  • Incontinence
  • Lower limb lymphoedema.

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 cell. 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 cell, small cell undifferentiated, lymphomas and sarcomas.

Cervical cancer staging

You may be asked to have various diagnostic test which help understand your cancer better. These could include: a pelvic examination, an MRI or PET-CT, chest x-ray or blood tests. Your consultant needs information to understand the extent your cancer has progressed and if the cancer cells have spread to other parts of the body. This process is called staging. Knowing the stage of the disease helps your consultant plan treatment. 

Carcinoma of the cervix: staging cervical cancer (primary tumour and metastases) 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 specialises 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.

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.

Cervical Cancer Screening

Cervical Cancer Screening (Pap Test, also known as: Pap Smear)

Cervical cancer screening is NOT a test to find cancer. It is a screening test to detect abnormalities (pre-cancer) at an early stage in the cells of the cervix.

Cervical cancer screening is the process of taking a sample of cells from your cervix, which are then examined to detect abnormalities that could develop into cancer in the future. The sample of cells is placed in a liquid so that it can be analysed in the laboratory. This process is called Liquid-Based Cytology (LBC). Screening can detect precancerous/abnormal cells. The detection and successful treatment of these cells usually prevent the occurrence of cancer. Changes in these cells are generally caused by certain types of human papillomavirus (HPV). Testing for the HPV virus itself can also be done on the same LBC sample that is examined under the microscope. For more information on HPV testing click here.

Around 1,408 new cervical cancer cases are diagnosed annually in Canada 1. Regular cervical screening provides a high degree of protection against developing cervical cancer. Not receiving cervical screening is one of the biggest risk factors for developing cervical cancer.

Those with Compromised Immune Systems

Women who have a severely compromised immune system such as HIV may need to be screened annually as they are more likely to develop a persistent infection of HPV which can over time cause cervical abnormalities. Women who are HIV positive will need to attend screening every year, the screening test is usually taken outside of the National Screening program. Men with severely compromised immune system are also at higher risk of contracting HPV. Please check with your health care professional for further information on screening and vaccination.

Not Eligible for Cervical Screening – Under 25

Each year in Canada, approximately 1,408 are diagnosed with cervical cancer. Cervical cancer is the 3rd most common female cancer for women aged between 14 and 44 years old in Canada 1. The number of young women diagnosed will be reducing over the next ten years due to the HPV vaccination program which offers the vaccine to girls under 18 years of age. This program was introduced in 2008 and will help to prevent the majority of cervical cancers 2

Those young women who are diagnosed with cervical cancer under the age of 25 often experience typical symptoms prior to diagnosis.

Symptoms of cervical cancer

The most common symptom is:

  • Abnormal vaginal bleeding, in between periods, during or after sex.

Other symptoms include:

  • Unusual and/or unpleasant vaginal discharge,
  • Discomfort or pain during sex
  • Lower back pain.

Abnormal vaginal bleeding is quite common, and is usually not serious. If a woman is experiencing symptoms such as abnormal bleeding she does not require a cervical screening test but will need to be examined by her GP and should undergo a direct examination of the cervix in order to rule out the very small chance that a cancer is present. 

Vaginal bleeding is extremely common and can be caused by a range of different problems including changes to the cervix (neck of the womb) called ectropion or cervical erosion, changes in hormones due to the contraceptive pill or benign cervical polyps or a sexually transmitted infection such as Chlamydia. The guidelines explain to GPs about the types of questions they need to ask to establish if the symptoms could be related to cervical cancer. A pelvic exam can be done by a GP. 

If you are experiencing any of these symptoms or are concerned about any new symptom it is important that you make an appointment to see your GP as soon as possible. Some women find it embarrassing to talk about gynaecological problems. If you feel like this, you are not alone. In a recent survey 80% of women said they would see a doctor for a cold that lasted more than 3 weeks, compared to only 50% if they bled outside of a period 19. However, your GP will not be embarrassed and they are used to talking about these subjects. Because abnormal bleeding can be a symptom of cervical cancer it is vital you seek some advice from your GP. If you want to you can also take a relative or a friend with you who can support you during your appointment with the GP. 

You might also find it helpful to take the Department of Health guidance along with you to discuss with your GP.

Why does cervical screening start at 25?

According to the most recent research, abnormal cervical cells are caused by high risk infection with HPV and are very common in women under 25. They are less common in older women. 

A high risk HPV infection has no symptoms so for most women they will be infected and not even know. Whilst a woman has high risk HPV, the infection can cause cells of the cervix to become abnormal (these abnormalities are sometimes called pre-cancerous changes). For most women these cervical abnormalities will clear up by themselves as the body’s own immune system gets rid of the HPV infection 20. Some women are unable to clear high risk HPV and the abnormal cervical cells caused by this infection could with time turn into cervical cancer. 

Because high risk HPV infections are common in young women, screening young women means that there would be a high number of women receiving a positive result indicating that they have abnormal cervical cells that would require further investigation. Most women with high risk HPV will clear the infection within 12 to 18 months and then the cervical abnormalities will go back to normal. But medical experts do not currently have a way to understand which women will be able to clear their abnormalities and which could go on to have cancer. However, they do know that if a woman is older than 25 and abnormal cells have not cleared up on their own, there is a greater need to offer treatment. 

So if young women are more likely to have abnormal cells this means these women will be more likely to be sent for treatment to remove the abnormal cells following a screening test. 

Treatment for cervical abnormalities has been shown to increase the risk of preterm labour and cause unnecessary anxiety for the woman. 216228

Diagnosis and treatment for cervical abnormalities has been shown to cause significant psychological trauma and, considering the majority of young women will clear these abnormalities without treatment, it means screening and subsequent treatment for abnormalities could cause more harm than the benefits of screening can provide. 

Additionally cervical screening has been shown not to be very effective in young women. In countries where screening started at 20, rates of cervical cancer in women under 25 are not significantly different to countries that start screening at 25 23

The International Agency for Research on Cancer also recommends that women should not start cervical screening before the age of 25.

Summary

  1. Cervical cancer is very rare in women under 25.
  2. Abnormal vaginal bleeding can be a symptom of cervical cancer – there are guidelines in place for the under 25s with abnormal bleeding. You should see your GP if you are bleeding outside of your period or after sex.
  3. Cervical screening (the smear test) is not recommended for women under 25.

What will happen during my Cervical Screening?

Having your cervical screening sample taken should only take a matter of 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 GP 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. 

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 GP/nurse will then insert an instrument called a speculum into your vagina. Some clinicians may use lubricant on the speculum which will make it easier to insert into the vagina. The speculum gently opens your vagina allowing the GP/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 GP/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 the microscope in the laboratory. 

In the laboratory, the contents of the vial are spun and treated to remove obscuring material. 

For most women, cervical screening is not painful but it may feel a little uncomfortable, therefore, if you experience any pain or other problems please do 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 to be taken 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 GP surgeries will ask you to book the test so do take you menstrual cycle into account before your book your screening test.

Helpful tips before your cervical screening

For many women the thought of going for cervical screening is often worse than the reality. Do not worry if you feel anxious about having your screening test, this is normal and many women 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 GP or practise 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 a vaginal oestrogen 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.

Testing for HPV

The HPV test is carried out using the same sample of cells taken during a cervical screening test. In the laboratory the cells are analysed for current HPV infection. 

The HPV test is important because it identifies women with a high risk type of HPV. If a woman contracts high-risk HPV and this becomes a persistent infection then she has a higher possibility of developing abnormal cells and thus should be monitored more closely to reduce her risk of developing cervical abnormalities and cervical cancer. 

The HPV test is carried out using the same sample of cells taken during a cervical screening test. The results of the HPV test combined with cervical screening cytology (examination of the cells under a microscope) enable faster investigation of those at higher risk of developing cervical cancer, and reassurance of those at very low risk. The test can also reduce the number of unnecessary screening appointments and colposcopies among women with borderline/mild cervical screening cytology results or who have been treated for abnormal cells. 

In the laboratory, the sample of cells is analysed for high risk HPV infection. If the cells have been infected with HPV, the test will give a positive result for high risk HPV types.

You can read more about HPV testing by downloading our HPV testing factsheet.

You can also order an at home HPV test through Eve kit: https://evekit.com/shop/ 

Results of Screening

Once your cervical screening has been taken it will be reviewed by specialists at a cytology* department, so, the length of time taken to receive your screening results can vary. Make sure you ask when you have your screening, how and when they will let you know your test result. 

If there are no abnormalities seen (the test is ‘negative’) you will be sent a letter confirming the result by your local Health Authority. Sometimes the hospital may contact you with the result. Some GP’s request the patient to ring for their result – do check if they would like you to do this. A negative results means you will be recalled for screening in three or five years dependent on where you live and your age. 

If the specialist looking at your cervical screening test feels it would be advisable for you to be reviewed by a hospital doctor then they will inform your GP. In some areas there is an agreement between the hospital and the GP’s surgeries that the woman is informed by letter directly from the hospital, and an appointment is made and enclosed in the same mailing. 

More than nine out of ten screening results are negative 1 and around one in 20 show mild cell changes called mild dyskaryosis. For most women with mild cell changes, the cells will go back to normal without treatment. 

One in a 100 test results show moderate cell changes (moderate dyskaryosis) and one in 200 show severe changes (severe dyskaryosis). If your results indicate that you have cell changes, you will be sent for colposcopy to investigate further. 

It is extremely rare for cancer to be diagnosed from a cervical screening test. Less than one in a thousand women test results show invasive cancer.

Cervical Screening in Summary

  • Remember an abnormal screening result rarely means cancer
  • Between 90 and 94% of all screening results are negative
  • Having regular cervical screening offers the best protection against developing cervical cancer
  • Cervical screening is free and you should talk to your doctor about getting regular screening.
  • If you are feeling anxious beforehand ask a member of your family or friend to accompany you. Your doctor or nurse will be happy to talk through any anxieties that you have prior to your cervical screening appointment.

Head and Neck Cancers

Head and Neck Cancer – What you need to know

Head and neck cancer is the sixth most common malignancy in the world. It occurs in the throat, mouth and nasal cavity and accounts for 6% of all cancer cases worldwide. In Canada, more than 4,300 people are diagnosed with this cancer every year.

Find out more about what you need to know about head and neck cancer below:

 What is head and neck cancer?

Head and neck cancers occur in the throat, mouth, tongue and nasal cavity.

About 90% of head and neck cancers (HNC) originate in the squamous cells lining the mucosal surfaces of the mouth, nose and throat, including the larynx. Less common types of HNC occur in the thyroid, salivary glands or nasopharynx, the top of the throat near the nasal cavity.

Commonly diagnosed in people 50 and above, head and neck cancers are twice as frequent in men than in women.

Risk Factors

Important risk factors for HNC are:

  • Human papillomavirus (HPV): More than 75% of HNC are caused by HPV. They typically involve the tonsils or the tongue. For more information on HPV, visit: https://hpvglobalaction.org/hpv-info/.
  • Alcohol and tobacco: Smoking – including secondhand smoke – chewing tobacco and alcohol use also cause HNC.

Other risk factors include:

  • Radiation exposure: Excessive radiation to the head and neck area is a risk factor, particularly for salivary gland cancer.
  • Epstein-Barr virus: Epstein-Barr virus, also known as human herpesvirus 4, is a risk factor for cancers of the nasopharynx and salivary glands.
  • Genetics: Asian ancestry, particularly Chinese, is a risk factor for nasopharyngeal cancer.
  • Poor oral or dental hygiene: Poor oral hygiene, missing teeth and prolonged use of high-alcohol mouthwash may be risk factors.
  • Environmental or occupational inhalants: Prolonged exposure to various particles, such as wood or metallic dusts, or chemicals such as formaldehyde, is risky.
  • Dietary factors: Poor nutrition and/or excessive consumption of preserved or salted foods during childhood are risk factors.

Prevention

Prevention is the most effective way to avoid HNC:

  • Get vaccinated against the human papillomavirus (HPV). Vaccinations are available in Canada to males and females aged 9 to 45. These vaccinations also prevent other cancers, such as cervical cancer in women. For more information on HPV vaccination, visit: https://hpvglobalaction.org/hpv-info/.
  • Stop using tobacco of any kind, but particularly smokeless tobacco used in the mouth or nose.
  • Avoid alcohol or at least consume in moderation.
  • Maintain good oral hygiene practices.
  • Reduce dietary and nutrition risks.
  • Use appropriate protective equipment at work when exposed to chemicals mentioned in the section on Risk factors.

Signs and Symptoms

Head and neck cancers are curable if the signs and symptoms are caught early. Be vigilant and conduct regular self-exams. It could save your life.

Here is a list of key things to look for. While many of these are also symptoms of non-cancerous conditions, you should have them examined by a physician if any of them persist.

  • A sore, swelling or ulcer in the mouth that doesn’t go away
  • A lump in the neck that lasts more than two weeks
  • A white or red patch in the mouth
  • Persistent earache or sore throat or nasal congestion
  • Pain in the mouth, jaw or ear without obvious cause
  • Voice changes or hoarseness lasting longer than two weeks
  • Difficulties with swallowing
  • Blood appearing in the saliva or phlegm for more than a few days

Early Detection

You can take the following measures to ensure early detection and diagnosis. Early detection increases the chances of a successful treatment and better health outcomes:

  • Perform monthly self-exams of your face, neck, lips, nose and inside your mouth to find any lumps, sores or abnormalities that may be early signs of head or neck cancer.
  • Ask your dentist and/or physician to perform an oral, head and neck exam to seek or check on abnormalities.

Diagnosis and Staging

If your general practitioner (GP) suspects a possible cancer, you will be referred to a specialist for further tests. The specialist will likely perform a thorough head and neck exam, including feeling in affected areas for abnormal lumps and using special tools or equipment to allow them to see inaccessible areas. These exams can include passing tools down the throat or into the nose. Depending on the type of problem, x-rays or other imaging scans may be used.

A biopsy will be done if a tumour or other suspected abnormal tissue is found. Usually performed with either a local or general anesthetic, a biopsy involves removing a small portion of the abnormal tissue so it can be examined in a laboratory. If it is found to be cancerous, further analysis will determine the nature of the cancer (e.g., squamous cell, other).

Biopsies as well as the other tests performed will help determine the stage of the cancer. These findings will dictate the kind and duration of treatment. HNC can be characterized by size or spread from Stage 1 to 4. The higher the number the more serious the disease. The smaller the number, the more likely that treatment will be successful.

It is important to remember, however, that it is sometimes possible to effectively treat advanced Stage 4 cancers with the therapies that are now available.

Treatments

Potential treatments for HNC include chemotherapies, immunotherapies, gene-targeted therapies radiation and surgery. They are often used in combination. The treatment plan for an individual depends on the exact location of the tumour, the stage of the cancer, whether it is caused by HPV, and the person’s age and general health.

Immunotherapy is the newest form of HNC treatment approved by Health Canada. It activates the patients’ own immune system to help it recognize and kill the cancer cells.

Life After Treatment

HNC can take both an emotional and physical toll on people. Even with successful treatment, dealing with the effects of the disease or treatment is a life-long experience.

For example, head and neck cancer treatment can leave people with scars, changes in appearance, partial paralysis of the face, or problems with speech. Often, speech or other physical therapy are prescribed. Lack of saliva, challenges with swallowing and/or diet restrictions round out common post-treatment adverse effects. Diet and nutrition are especially important after treatment.

Sometimes, people are traumatized by the experience and need emotional support. Some patients live in fear that their cancer might return. As well, the emotional changes during a cancer journey can make re-establishing relationships difficult for some.

It is important for patients to be alert to their emotional well-being and discuss their feelings frankly with close family and friends. If necessary, they should seek professional help.

Other Resources

Head and neck patients and their caregivers face many challenges during and after their treatment. Here are a few resources that may help inform and support during the cancer journey:

Tonsil and vocal cord cancer

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Tongue Cancer

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Throat Cancer

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Anal Cancer

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Vulvar Cancer

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Vaginal Cancer

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Penile Cancer

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Vaccines

The Vaccines

There are currently two vaccines which protect against HPV infection. These are called Gardasil and Cervarix. Cervarix is only for women.

  • Gardasil9 is designed to protect against nine different types of HPV.
  • HPV types 12, 18, 31, 33, 45, 52 and 58 that cause cervical cancer
  • HPV types 16, 18, 31, 33, 45, 52, 58 that cause vulvar and vaginal cancer
  • HPV types 16, 18, 31, 33, 45, 52 and 58 that cause anal cancer
  • HPV types 6 and 11 that cause genital warts
  • HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58 that cause abnormal and precancerous anal lesions
  • HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58 that cause abnormal and precancerous cervical, vaginal, and vulvar lesions
  • Cervarix is designed to protect against HPV types 16 and 18. It also helps protect females between that ages of 10 and 25 against precancerous conditions and cancers of the cervix.

Both vaccines are licensed in Canada.

The HPV vaccine works best if given before a person comes into contact with HPV, as the virus is transmitted through skin to skin sexual contact below the waistline even without penetration with fingers, mouths or other body parts, also condoms do not fully protect people from giving/getting this virus because the condom only covers the length of the penis and there are still other parts below the waist that will have direct skin to skin contact. To be clear, a person comes into contact with this virus when using their mouth, hands, or fingers below the waistline of a partner. As previously mentioned, this also includes putting a penis or an object in a vagina or a butt, and rubbing against each other with skin to skin contact below the waistline even without any penetration.

In practical terms, the easiest and most effective way to reach everybody is for girls and boys to be vaccinated before they are sexually active. In Canada, the vaccination programs for HPV are implemented for girls and boys in schools between grades 5 and 8 depending on the province.

Vaccines are given by injection into the muscle, usually the upper arm. Two separate doses are needed. The second dose should be given anytime between six to 12 months after the first, but it can be given up to 24 months after.

There is some evidence that the HPV vaccines provide cross protection for other types of HPV which may mean that it has a higher protection level than first thought 1219. Research indicates that the HPV vaccine could prevent two thirds of cervical cancers in women aged below 30 by 2025 but only if uptake of the HPV vaccination is at 80% 20.

The Vaccination Program

The Canadian national HPV immunization program was introduced into schools in 2007, 2008, 2009 and 2010 depending on the province. This program is offered to boys and girls (depending on the province and territory) and first vaccination occurs between grades 4 and 8 depending on location. (An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI)† Update on Human Papillomavirus (HPV) Vaccines)).

The vaccines are over 98% effective in preventing cervical abnormalities associated with HPV 16 and 18 in women who have all three doses and in those who have not yet been infected with HPV 1181920. However, efficacy is decreased if the vaccinated woman has already contracted the virus. Recent research shows that antibody response to two doses in adolescent girls is as good as a three dose course in the age group.

More information on the HPV vaccination program:

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/12vol38/acs-dcc-1/index-eng.php

If you are not eligible for the free vaccine you can pay for it privately. Some local pharmacists also offer the vaccine. Talk to your healthcare provider about the HPV vaccine.

The HPV vaccination will help reduce the number of cases of HPV related cancers and the number of individuals who have to be treated for genital warts or HPV-related cancers. Whether girls/women have been vaccinated or not, the best protection against cervical cancer is to continue going for regular Pap tests and HPV tests for women over 30. The combination of HPV vaccination and cervical screening can help reduce cervical cancer incidence in Canada.

Free HPV immunization programs by province/territory :

click here to see the Free HPV immunisation programs in your province/territory
Advisory Committee Statement (ACS) and National Advisory Committee on Immunization (NACI). (2012). Update on Human Papillomavirus (HPV) Vaccines. Canada Communicable Disease Report. Vol. 38

Side Effects Caused by Vaccination

Thousands of girls and women of different ages took part in the clinical trials for the HPV vaccines 1. These trials found that the vaccine offers 98% protection against infection with the high-risk types of HPV in girls who haven’t previously been infected with the virus. Side effects from both vaccines are usually mild.

Side effects for the Gardasil HPV vaccine include 18:

Very common side effects (side effects which may occur in more than one per 10 doses of vaccine) reported by girls who have received the vaccine are:

  • Injection site problems such as redness, bruising, itching, swelling, pain or cellulitis
  • Headaches
    • Common (side effects which may occur in less than one per 10 but more than one per 100 doses of vaccine):
      • Fever
      • Nausea (feeling sick)
  • Painful arms, hands, legs or feet
    • Rare (side effects which may occur in less than one per 100 but more than one per 1,000 doses of vaccine):
  • More than one in 10,000 people who have the Gardasil HPV vaccine experience:
    • An itchy red rash (urticaria)
  • Fewer than 1 in 10,000 people who have the Gardasil HPV vaccine experience:
    • Restriction of the airways and difficult breathing (brochospasm)

For information on side effects for the HPV Vaccine, please see these websites:

  1. http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/12vol38/acs-dcc-1/index-eng.php#a4-8
  2. http://www.gardasil.com/about-gardasil/about-gardasil/
  3. http://www.gsk.ca/english/docs-pdf/product-monographs/Cervarix.pdf

References

The Vaccines.

  1. Wheeler C. et al., 2009. The Impact of Quadrivalent Human Papillomavirus (HPV; Types 6, 11, 16, and 18) L1 Virus-Like Particle Vaccine on Infection and Disease Due to Oncogenic Nonvaccine HPV Types in Sexually Active Women Aged 16-26 Years. J Infect Dis, 199(7), 936-44.
  2. Szarewski A. 2008. HPV vaccines: peering through the fog. Journal of Family planning and Reproductive Health Care 34(4), 207-209.
  3. Malagon T. et al., 2012. Cross-proective efficacy of two human papillomvirus vaccines: a systematic review and meta-analysis. The Lancet Infectious Diseases 12, 781-789.
  4. Cuzick J, Castanon A, and Sasieni P. 2010. Predicted impact of vaccination against human papillomavirus 16/18 on cancer incidence and cervical abnormalities in women aged 20–29 in the UK. British Journal of Cancer 102, 933-939.

The Vaccination Program.

  1. Paavonen J. et al., 2009. Efficacy of human papillomavirus (HPV) -16/18 AS04- adjuvanted vaccine against cervical infection and precancer caused by oncogenic HPV types (PATRICIA): final analysis of a double-blind, randomised study in young women. The Lancet, 374 (9686), 301-14.
  2. Szarewski A. 2012. Cervarix®: a bivalent vaccine against HPV types 16 and 18, with cross-protection againstother high-risk HPV types. Expert Rev. Vaccines 11(6), 645–657.
  3. Dillner J. et al., 2010. Four year efficacy of prophylactic human papillomavirus quadrivalent vaccine against low grade cervical, vulvar, and vaginal intraepithelial neoplasia and anogenital warts: randomised controlled trial. BMJ 341: c3493. Available online: http://www.bmj.com/content/341/bmj.c3493. Accessed 03.05.2013.
  4. Kjaer S. et al., 2009. A pooled analysis of continued prophylactic efficacy of quadrivalent human papillomavirus (Types 6/11/16/18) vaccine against high-grade cervical and external genital lesions. Cancer Prevention Research 2 (10), 868-878.

Side Effects Caused by Vaccination.

  1. Schiller JT. et al. 2008. An update of prophylactic human papillomavirus L1 virus-like particle vaccine clinical trial results. Vaccine, 26 (10), K53-61.
  2. NHS choices website: http://www.nhs.uk/Conditions/HPV-vaccination/Pages/Side-effects.aspx. Accessed 03.05.2013.
  1. Koutsky L. 1997. Epidemiology of genital human papillomavirus infection. The American Journal of Medicine, 102 (5A), 3-8
  2. 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
  3. Giuliano AR et al., 2008. Epidemiology of human papillomavirus infection in men, cancers other than cervical and benign conditions. Vaccine, 26 (10), K17-28
  4. Walboomers JMM et al.,1999 Human papillomavirus is a necessary cause of invasive cancer worldwide. Journal of Pathology, 189 (1), 12–19
  5. Szarewski A. 2012. Cervarix: a bivalent vaccine against HPV types 16 and 18, with cross-protection against other high-risk HPV types. Expert Review Vaccines 11(6), 645 – 657
  6. Bouvard et al., 2009. A review of human carcinogens – Part B: biological agents. Lancet Oncology 10, 321 – 32
  7. Winer RL et al., 2003. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. American Journal of Epidemiology 157 (3), 218-226
  8. Dunleavey R (2009) Cervical Cancer: a guide for nurses. Wiley-Blackwell, UK. pp
  9. Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, Brotons M, Mena M, Cosano R, Muñoz J, Bosch FX, de Sanjosé S, Castellsagué X. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Canada. Summary Report 2014-12-18
  10. Cancer Research UK – http://www.cancerresearchuk.org/cancer-info/cancerstats/types/cervix/inc…. Accessed 10.09.14
  11. Meshera D et al., 2013. Reduction in HPV16/18 prevalence in sexually active young women following the introduction of HPV immunization in England. Vaccine 32(1), 26-32
  12. Jo’s Cervical Cancer Trust – http://www.jostrust.org.uk/news/articles/2013/01/21/third-more-women-lik…. Accessed 10.09.14
  13. Kim JW et al., 2012. Factors affecting the clearance of high-risk human papillomavirus infection and the progression of cervical intraepithelial neoplasia. Journal of International Medical Research 40(2), 486-96
  14. Poon LC et al., 2012. Large loop excision of transformation zone and cervical length in the prediction of spontaneous preterm delivery. BJOG 119(6), 692-8
  15. Kyrgiou M et al., 2006. Obstetric outcomes after conservative treatment for intraepithelial or early invasive cervical lesions: systematic review and meta-analysis. Lancet 367(9509), 489-98
  16. Jakobsson M et al., 2007. Preterm delivery after surgical treatment for cervical intraepithelial neoplasia. Obstetrics Gynecology 109 (2 Pt 1), 309-13
  17. Noehr B et al., 2009. Loop electrosurgical excision of the cervix and subsequent risk for spontaneous preterm delivery: a population-based study of singleton deliveries during a 9-year period. American Journal of Obstetrics & Gynecology 201(1), 33.e1-6
  18. 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
  19. Giuliano AR et al., 2008. Epidemiology of human papillomavirus infection in men, cancers other than cervical and benign conditions. Vaccine, 26 (10), K17-28
  20. Walboomers JMM et al.,1999 Human papillomavirus is a necessary cause of invasive cancer worldwide. Journal of Pathology, 189 (1), 12–19
  21. Szarewski A. 2012. Cervarix: a bivalent vaccine against HPV types 16 and 18, with cross-protection against other high-risk HPV types. Expert Review Vaccines 11(6), 645 – 657
  22. Winer RL et al., 2003. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. American Journal of Epidemiology 157 (3), 218-226
  23. Bruni L, Barrionuevo-Rosas L, Albero G, Aldea M, Serrano B, Valencia S, Brotons M, Mena M, Cosano R, Muñoz J, Bosch FX, de Sanjosé S, Castellsagué X. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Canada. Summary Report 2014-12-18