WHAT IS THE CERVIX?

The cervix is a typically two-inch long muscular tube that connects the uterus to the vagina. The cervix has two parts, each with its own type of lining cells. The endocervix is the opening of the cervix and it leads into the uterus. The surface of this part of the cervix is covered with glandular cells. These cells produce cervical mucus. The ectocervix is the outer part of the cervix and it is covered in non-keratinized squamous cells, which are similar to those that line the inside of the mouth.

Anyone with a cervix can be at risk for cervical diseases including cervical cancer, but through regular screening with a healthcare provider, many of these diseases and most cancers are preventable.

CERVICAL DISEASES

Cervical diseases include the following conditions:

Cervicitis, which is inflammation of the cervix.
Nabothian cysts, which are small bumps that develop when surface lining cells clog the mucus-producing glands near the surface of the cervix.
Genital condylomas, which are also called genital warts, are non-cancerous warts.
Low-Risk Human Papillomavirus (HPV), which can also cause genital warts.
Low-grade squamous intraepithelial lesions (LSIL), which are also called mild cervical dysplasia, are areas of abnormal tissue. These are not cancerous but have the potential to develop into cancer.
High-grade squamous intraepithelial lesions (HSIL), which include moderate cervical dysplasia, severe cervical dysplasia, and carcinoma in-situ. They are also areas of abnormal tissue that could develop into cancer. HSILs are more likely to progress to cancer than LSILs.

Because cervical conditions rarely have symptoms in the early stages, laboratory testing at appropriate intervals is especially important to detect issues.

RESOURCES

Educational Materials: Cervical Diseases

Español: Pruebas De Laboratorio Relacionados Con Enfermedades Y Cancer Cervical

CERVICAL CANCER

Cervical cancer is a malignant tumor of the cervix.

The transformation zone between the endocervix and the ectocervix is where the two types of cells, glandular and squamous cells, meet. Most cervical cancers start in this area.

The most common types of cervical cancer are squamous cell carcinoma (SCC) and adenocarcinoma (ADC). Less common, but also possible, is a combination of SCC and ADC. SCC typically begins in the transformation zone and develops from cells in the ectocervix. ADC typically develops in the from glandular cells of the endocervix.

STAGES OF CERVICAL CANCER

The stages of cervical cancer determine how far the cancer has spread and what parts of the body it has spread to. A patient’s treatment plan and prognosis will depend on the staging portion of your diagnosis. Below is a short description of each stage:

STAGE 0: Pre-cancerous cells (also called carcinoma in-situ) are only found in the innermost lining of the cervix. This is not technically cancer. If a growth is diagnosed at this stage, it is completely curable. Doctors may also call these growths high-grade squamous intraepithelial lesion (HSIL) and/or cervical intraepithelial neoplasia (CIN) III.
STAGE I: The cancer has invaded the cervix and possibly the uterus.
STAGE II: The cancer has spread beyond the uterus, but not to the lower part of the vagina or the pelvis.
STAGE III: The cancer has spread to the lower part of the vagina and the pelvis, but not to other parts of the body or lymph nodes.
STAGE IV: The cancer has spread to other parts of the body; the cancer has metastasized.

UNDER THE MICROSCOPE

This is an image of a Pap test slide showing cervical cancer. The long slender snake-like cells have abnormal DNA and are interspersed amongst tissue necrosis (dead tissue). These cellular elements are indicative of cervical cancer, also known as squamous cell carcinoma.

CERVICAL CANCER AND HPV

Human Papillomavirus (HPV) is the most common sexually transmitted infection (STI) and the number one cause of cervical cancer. There are over 150 different types of HPV and 40 of these can affect the genitals. Most HPV infections do not pose a serious health risk. In fact, 9 out of 10 times, new HPV infections will go away or become undetectable without treatment.

Doctors and scientists divide the 40 types of HPV that affect the genital area into two categories: low-risk HPV and high-risk HPV.

Low-risk HPV types are usually easily destroyed by the immune system and do not cause symptoms. However, some types of low-risk HPV can cause genital warts on the vulva, penis, cervix, or anus. Low-risk HPV does not cause cancer.

High-risk HPV are the types that cause the most changes to cells in the cervix and can cause cancer. Two types, HPV 16 and HPV 18, cause the majority of squamous cell carcinomas and HPV 16, 18, and 45 are associated with most adenocarcinomas.

CAN YOU PREVENT HPV?

The HPV vaccine protects against nine types of HPV, including the types most likely to cause cancer and genital warts. The three-dose vaccine is recommended for all children, no matter their sex or gender, during routine vaccination starting at age 9. The HPV vaccine prevents new HPV infections but does not treat existing HPV infections or diseases. Studies show that if patients are vaccinated against HPV before they become sexually active, it reduces their chance of genital warts and cancer caused by HPV by up to 99%.

Once people become sexually active, they can protect themselves and their partners from HPV with safer sex practices, including using condoms and regular STI testing.

LABORATORY TESTS RELATED TO CERVICAL DISEASES AND CANCER SCREENING

The goal of routine pelvic examination is to find cervical diseases, pre-cancer, or cancer early when it is more easily treatable. Regular cervical cancer screening (part of the routine pelvic exam) is highly effective at preventing cervical cancer and saving lives. Most healthcare providers recommend cervical cancer screening for all people with a cervix starting at age 21 and continuing until they are 65 (if there is no history of abnormal screening results). The screening process involves your healthcare provider taking a sample of cells from the cervix during a pelvic examination. The types of tests that may be performed include:

PAP TEST: This is the most common test used to detect cervical cancer and its precursors. Sometimes, it is called a Pap smear. The sample for this test is collected during a cervical examination at a doctor’s office. These tests are usually performed by a gynecologist. They will use a device called a speculum to open the patient’s vagina to see the cervix. Then they will use a small brush to collect cells from the surface of the cervix. These cells are sent to the lab, where a cytologist will use a microscope to look for any abnormal cells. If abnormal cells are discovered, the slide is reviewed by a pathologist who makes the diagnosis.

This screening test is important because it can detect growths that can turn into cancer even when physical symptoms are absent. Pap test results will be either “normal” or “abnormal.” Normal results mean the sample only contained normal cervical cells and there is no need for additional testing. Abnormal results mean there were abnormal cells found in the sample. Abnormal results do not mean the patient has cancer. Patients with abnormal Pap test results will need to get additional testing.

Guidelines recommend that a Pap test is conducted at least every 3-5 years, unless there is an increase in risk of cervical cancer due to presence of high-risk HPV, previous abnormal Pap tests, or other personal or family health history.

HUMAN PAPILLOMAVIRUS (HPV) TEST: This test screens for the presence of a high-risk HPV virus but it cannot detect cervical cancer. Like a Pap test, the test sample is collected during an in-office exam by a doctor using a small brush. The sample is sent to a lab, where a laboratory scientist checks it for the presence of genetic material from certain high-risk types of HPV. If the result is positive, the patient will need a Pap test to determine whether HPV has caused precancerous changes in the cells of the cervix.

HPV + PAP (CO-TESTING): This process uses the same sample for both a Pap test and an HPV test. Co-testing increases the chances of finding abnormal cells, cervical disease, or predicting the severity of cervical disease, and is the most sensitive method for cervical cancer detection.

HOW OFTEN TO GET SCREENED

The current guidelines for cervical cancer screening depend on the age of the patient and their risk factors. The American College of Obstetrics and Gynecologists (ACOG) recommend the following screenings (Patients with HIV, a weakened immune system, or a history of cervical cancer may need additional screening): cervical_cancer_hpv_screening_4

WHAT HAPPENS IF I GET AN ABNORMAL PAP TEST RESULT?

If a patient’s Pap test comes back as abnormal, their healthcare provider will work with them to determine appropriate next steps. Abnormal tests are common and do not always mean the patient has cervical disease or cancer. Most patients with abnormal results will need a follow-up procedure called a colposcopy to check for cervical disease and cancer.

COLPOSCOPY: This test identifies abnormalities by closely examining your cervix using an instrument that magnifies (40X) the surface of the cervix, vagina, and vulva. If there are abnormal lesions, a biopsy will be taken (see below). This test is usually conducted after an abnormal Pap test or a high-risk HPV test result. This test is not to be confused with a colonoscopy, which is a test used to detect abnormalities in the large intestine or rectum.

COLPOSCOPIC BIOPSY: During a colposcopy, a small section of an abnormal area in the cervix may be removed. If so, these cells will be examined under a microscope in the laboratory.

ENDOCERVICAL CURETTAGE: This biopsy comes from tissue within the endocervix, which is located farther within the cervix, closer to the uterus. This type of biopsy is conducted when the colposcopic biopsy does not reveal any abnormal areas or if it is it not possible to see the transformation zone with a colposcope.

CONE BIOPSY: This biopsy involves the cervical transformation zone, where cancerous cells are most likely to originate. This type of biopsy can also be used as a treatment to remove some early pre cancers or stage 1 cervical cancers.

QUESTIONS TO ASK YOUR DOCTOR

What is the course of action based on my lab results?
How will the lab test results impact my treatment plan?
What are all my treatment options?
Why do you recommend this particular treatment option?
What tests are used for my cervical screening?
How often should I be screened for cervical cancer?
How do we know the procedure was successful/what lab tests and which results indicate a successful procedure?
If malignant, what are the tumor markers we are monitoring? What are the levels we are considering?
What happens if the tumor markers are higher than we would like to see?
What are the follow-up tests and what are their importance?

DANIELLE’S STORY

At age 24, Danielle received a call from her gynecologist stating that she had an irregular Pap test result. She still remembers this call so clearly and gets chills down her spine. She went in for a repeat Pap test and when that came back irregular as well, a biopsy was ordered. The lab had found she had high-risk HPV and pre-cancerous cells in her cervix. When I found out, I felt terrified and very lonely, says Danielle, I only heard the word “cancer” not the “pre”in front of it. Danielle underwent two cryosurgeries, a procedure in which freezing gas is used to remove pre-cancerous cells on the cervix. However, her lab tests showed that the pre-cancer was still there. She then underwent a Loop Electrosurgical Excision Procedure (LEEP) which removes abnormal tissue from the cervix and vagina to both diagnose and treat cervical disease with the help of a wire loop heated by electric current. After two years, three procedures, and many lab tests she finally received the Pap results she had been hoping for: all normal. “Without laboratory testing I would not have known that I had pre-cancerous cells in my cervix. I'm afraid to think of what my life would be like without laboratory testing, because it's highly likely that I wouldn't even be here to ponder the question.”

Danielle Was Diagnosed With HPV and Shares Her Story in Preventing Cervical Cancer

CORIE'S STORY

Before I was diagnosed with Chronic HPV, my life was normal. In 2002, I had gone in for a routine Pap smear and was told that I had HPV. My Pap results came back showing that I had both high-risk strains 16 and 18, which are the strains that are most likely to turn into cervical cancer. After doing some research and getting a few second opinions, I enrolled into a clinical trial which was monitoring women with high-risk HPV and their responses to certain treatments. This information was being used to better understand how aggressive some patients needed to be treated versus others in order to prevent cervical cancer from developing.

At my first visit with my clinical trial healthcare provider, I had a colposcopy, which is an internal exam to look at the cervix to see the specific areas of abnormality, followed by a LEEP procedure which removes abnormal tissue from the cervix to both diagnose and treat cervical disease. Unfortunately for me, the LEEP procedures did not work right away: initially it would look like everything was back to normal but months later I would again receive an abnormal Pap test. I would start feeling better, but then would experience bleeding again and it would be back to undergoing more biopsies and colposcopies

To help figure out what was going on and how I could manage my HPV effectively, I received multiple tests and treatments over the course of four years as part of the clinical trial. My biopsies from the laboratory would often come back with moderate abnormal development of cells (dysplasia) in my cervix. But over the years, lab tests showed that the abnormal cells became more and more invasive. This whole experience was very scary and it was an unnerving way to live because I was worried all the time about what was going to happen next.

My wife had previously been diagnosed with cervical cancer and I also have friends who had dealt with HPV issues, so I knew the risks of HPV. In 2010, I had another HPV flare up and this time my abnormal Pap came back yet again as having high-risk strains 16 and 18, meaning that if this was not taken care of, it could again lead to cervical cancer. My clinical health care provider then recommended that I undergo a Dilation and Curettage procedure (D&C) to remove abnormal tissue. After undergoing that, I was finally in the clear and felt relieved and hopeful about moving forward in my health journey.

Since her diagnosis, Corie has become heavily involved in the patient advocacy community to help women understand the importance of screening for HPV and getting Pap tests. She encourages people to get involved with cervical cancer organizations and has written a book with information about Pap smears and HPV testing and the importance of preventative testing. Her advice to other patients is to get as much information as you can about your condition so that you can talk in an educated way when you go to visit doctors. She also recommends to always seek out a second opinion as soon as you can in order to make the best decision for yourself.