Gynecology Topic 22. Symptoms, signs and screening of cervical cancer

I. Clinical Features

Phases of HPV-Related Cervical Disease

• Latent infection: HPV DNA positive; cytology/histology may be negative.
• Subclinical infection: CIN / abnormal cytology.
• Clinical disease: visible lesion or invasive cancer.

Symptoms of Cervical Cancer

• Early phase: mostly asymptomatic.
• Bleeding: postcoital bleeding, intermenstrual/irregular/heavy bleeding, postmenopausal bleeding.
• Discharge: watery, bloody, purulent or foul-smelling vaginal discharge.
• Advanced disease: pelvic/back pain, leg edema, urinary symptoms, hydronephrosis/hematuria, rectal symptoms, fistula symptoms.

Signs on Examination

• Speculum examination: cervical ulcer, exophytic/fungating mass, contact bleeding, foul/bloody discharge.
• Bimanual examination: uterus/adnexa; does not diagnose dysplasia.
• Rectovaginal examination: important for advanced disease → parametrial, rectal, pelvic sidewall involvement.
• Grossly abnormal cervix → biopsy, regardless of Pap smear result.

Patterns of Spread

• Direct invasion: cervical stroma → corpus, vagina, parametrium, bladder, rectum.
• Lymphatic spread: pelvic lymph nodes → para-aortic nodes.
• Hematogenous spread: lung, liver, bone.

II. Prevention and Screening

Primary Prevention

• HPV vaccination: best before sexual debut; vaccinate according to national program.
• Gardasil 9 covers HPV 6/11 and major high-risk types including 16/18/31/33/45/52/58.
• Condoms reduce HPV transmission but do not give complete protection.
• Vaccinated patients still need screening because vaccines do not cover all oncogenic HPV types and may be given after exposure.

Secondary Prevention: Screening

• Screening detects CIN before invasive cancer develops.
• Age 21-29: Pap smear/cytology every 3 years.
• Age 30-65: Pap smear every 3 years or HPV DNA test with/without Pap smear every 5 years.
• Age >65: stop if adequate previous tests were negative and no high-risk history.
• High-risk patients need individualized screening: HIV, immunosuppression, previous CIN 2+, cervical cancer, DES exposure.
• Local national screening programs may differ; follow local protocol in practice.

III. Pap Smear and HPV Testing

Pap Smear / Papanicolaou Test

• Definition: cytologic examination of cervical cells.
• Target area: transformation zone / squamocolumnar junction.
• Purpose: detect abnormal squamous or glandular cells before invasive cancer.

Procedure

1. Visualize cervix with speculum.
2. Collect cells from ectocervix and endocervix/transformation zone using spatula/cytobrush.
3. Conventional smear: spread cells on slide and fix; liquid-based cytology: place brush in preservative solution.
4. Send for cytology, with HPV testing if indicated.

Bethesda System

• Standardized reporting system for cervical/vaginal cytology.

1. Specimen adequacy / slide quality

• Satisfactory or unsatisfactory: poor sampling, blood/inflammation, fixation problems.

2. General interpretation

• Negative for intraepithelial lesion or malignancy.
• Epithelial cell abnormality.

3. Squamous cell abnormalities

• ASC-US: atypical squamous cells of undetermined significance.
• ASC-H: atypical squamous cells, cannot exclude HSIL.
• LSIL: low-grade squamous intraepithelial lesion, usually CIN 1.
• HSIL: high-grade squamous intraepithelial lesion, usually CIN 2-3.
• SCC: squamous cell carcinoma.

4. Glandular cell abnormalities

• AGC: atypical glandular cells.
• AIS: adenocarcinoma in situ.
• Adenocarcinoma.

5. Recommendation / next step

• Repeat testing, HPV triage, colposcopy, biopsy, or diagnostic excision according to risk.

HPV DNA Test

• Detects high-risk HPV types, especially HPV 16 and 18.
• Higher sensitivity than cytology for CIN 2+ detection.
• Lower specificity in young women because transient HPV infection is common.
• Used as primary screening, co-testing, or triage depending on age and local protocol.

IV. Colposcopy and Diagnostic Follow-Up

Colposcopy

• Definition: magnified examination of cervix, vagina and vulva to distinguish normal from abnormal epithelium.
• Indications: abnormal Pap/high-risk HPV according to risk, visible suspicious lesion, postcoital bleeding with suspicious cervix.

Extended Colposcopy

• Acetic acid: dysplastic high-nuclear-density epithelium turns white = acetowhite area.
• Lugol iodine / Schiller test: normal glycogen-rich squamous epithelium stains dark brown; dysplastic glycogen-poor epithelium remains iodine-negative.
• Directed punch biopsy from the worst abnormal area → confirms diagnosis.
• Endocervical curettage may be added if transformation zone is not fully visible or endocervical lesion suspected.
• ECC is contraindicated in pregnancy.

Abnormal Screening: Practical Logic

• Gross cervical mass/ulcer → biopsy immediately, do not rely on screening cytology.
• LSIL/HSIL or HPV-positive abnormalities → colposcopy according to risk-based/local protocol.
• HSIL cytology + unsatisfactory colposcopy, positive ECC, AIS, or suspected microinvasion → diagnostic cone biopsy.
• Pregnancy: expert colposcopy for suspicious lesions; defer treatment until postpartum unless invasion suspected.