On this page you can read about management of abnormal Cervical Screening Tests, the natural progression of HPV infections, and precancerous lesions of the Vulva.
From December 2017, screening for cervical cancer risk has changed. Read about it here. From this time forward the Australian Guidelines for managing abnormal smears have also changed. They can be read here. In January 2018, I completed the RANZCOG Colposcopy Online Learning Programme in order to bring myself up to date with the requirements for colposcopy providers.
Sometimes, even if your HPV test is normal, your GP will still want you to have your cervix further investigated by a specialist because of symptoms of bleeding after intercourse or because the cervix looks abnormal.
Once your GP has decided you need further investigation with a specialist, you may be referred for a colposcopy which is an examination of a woman's cervix (or neck of womb) using a microscope called a colposcope. The colposcope can also be used to examine for abnormal cells or lesions elsewhere in the woman's genital tract, but is not an operation and no anaesthetic or stay in hospital is necessary.
It is important to remember that the CST is designed to capture pre-cancerous disease, which is asymptomatic and easily treatable if a high grade lesion is found. It is very uncommon for women to develop invasive cancer if they have been having their tests at the recommended intervals.
At my office, my receptionists understand that women referred for colposcopy are usually very anxious to be seen quickly, and they will make every effort to assist you with a timely appointment, as well as fully informing you of the costs of the procedure, and the refund from Medicare (or your insurer if you are not eligible for Medicare).
When I see you we will discuss your full medical history, and any other gynaecologic issues you might have. The procedure of colposcopy is generally much like a longer pap smear test. A speculum is inserted into the vagina and the cervix is inspected with a microscope called a colposcope. A weak solution of acetic acid (vinegar) is applied to the cervix, and the cells are observed for suspicious changes. If a biopsy is necessary, it is generally well tolerated. If you suffer from a lot of menstrual cramps you might find it beneficial to take a simple analgesic like ibuprofen an hour before your appointment (so long as you are not allergic to this class of medicines).
During and after the procedure I will explain what I have found, and if you have a biopsy I will suggest you refrain from using tampons or having intercourse for a few days. There may be some blood stained discharge for a few days which gradually settles as the biopsy site repairs itself.
It usually takes a few days for the biopsy report to return, and I will contact you as soon as it is available to advise you as to whether further treatment is necessary. Generally, only high grade lesions need treatment, as most low grade lesions will resolve with observation.
The most common procedure, especially in younger women in whom the whole abnormality is generally visible is a LLETZ, although in women where the abnormality is extending into the canal, a cone biopsy may be necessary.
I perform these at the Wesley Day Surgery, under a very light anaesthetic, and patients are discharged on the day of surgery, generally without any pain. You may have a light, sometimes blood stained discharge for some weeks, and because it can take 3-4 weeks for the cervix to heal, it is wise to refrain from intercourse or the use of tampons during this month post-op.
The main complication to watch out for in the first 2 weeks post op is heavy bleeding when you are not expecting your period, as this may be a sign your body is struggling with a low grade infection that requires antibiotics. Infections arise from the bacteria that naturally live in the vagina, and usually don't become apparent until 10-14 days after the procedure. You should call me and report any unusually heavy bleeding, especially with blood clots, or fever, and we will attend to you immediately. Most women will only require oral antibiotics; it is very rare to need to be re-admitted for IV antibiotics.
I will call you with the results of the pathology examination of the LLETZ/cone biopsy specimen within a few days, and see you at 6 weeks to check healing of the cervix. We will then discuss follow up, which for most women will be a CST with their GP in 12 months.
For most women, they will be cured after their procedure, and can expect to have normal fertility and pregnancies in the future.
A special category is adenocarcinoma in situ. New guidelines will be coming into effect from December 2017.
Some benign lesions of the cervix
Cervical ectropion is a normal finding on the cervix of young women, which usually becomes smaller with age. It is not cancerous.
Sometimes incorrectly called an "erosion" it is in fact the presence of normal mucous secreting tissue on the outer part of the cervix. Because the blood vessels feeding the glandular tissue are close to the surface, it can result in a red appearance, and is more likely to bleed with pap smears and intercourse, as well as cause a heavier mucous discharge.
If these are significant problems, the woman might be offered a "diathermy" to facilitate the coverage of the external cervix with tougher skin like squamous cells (a process that occurs naturally with the passage of time).
Dr Melissa Buttini m.b.b.s franzcog
Image borrowed from American Family Physician Journal
Nabothian follicles, or cysts, are formed when mucous secreting glands of the cervix become blocked by the skin cells of the cervix. They are full of mucous, and usually swell to a maximum size of 1 cm or less, then stop growing.
They can look alarming to your doctor when you are having a CST, because they are often irregular in appearance and associated with large blood vessels, but they are quite benign, cause no problems, and require no specific treatment, once they have been checked out at colposcopy.
Vulval Pre Cancers and Cancers
Vulval pre cancers include squamous lesions associated with HPV virus, as well as lesions not associated with HPV, Paget’s disease (adenocarcinoma in situ) and melanoma in situ.
HPV associated Squamous Lesions.
Low grade lesions (LVSIL) are usually associated with HPV 6 or 11 and are rare in individuals who have received HPV vaccination. They rarely progress to cancer, often resolve spontaneously, and can be treated with ablation or the use of immunotherapies such as Imiquimod cream.
Vulval High Grade Squamous Lesions (VHSIL) are caused by HPV 16 in more than 60% of cases. Ten percent of VHSIL will progress to cancers if left untreated and the risk of progression to cancer is increased in smokers and the immunosuppressed.
Treatment may be by ablation/excision or the use of Imiquimod cream depending on the size and location of lesions. The aim is prevention of progression to invasive cancers, preservation of normal anatomy and sexual function, and relief of symptoms.
Long term follow up is required, as recurrences many years after treatment have been identified. Pre cancers can also develop elsewhere in the lower genital tract (cervix, vagina) so these sites need to be inspected. There is also an increased risk of developing anal cancers (an incidence ratio of 42/100 000 person years compared with a background incidence in the population of 1-2/100 000 person years). At present optimal anal screening has not been established, but certainly might be considered in immunocompromised individuals.
Studies are underway to examine the use of therapeutic vaccines.
Non HPV associated Squamous Lesions.
These are also known as Differentiated VIN or dVIN and have a much greater chance of becoming cancers than the HPV associated lesions (around 30-50%). Differentiated VIN mostly arises in association with inflammatory skin conditions such as Lichen Sclerosus and Lichen Planus, which is the reason these patients need frequent specialist review. Treatment with topical steroids has been shown to reduce the chance of developing dVIN in these patients.
When a biopsy diagnosis of dVIN has been made, treatment is ALWAYS by excision, under the care of a Gynaecologic Oncologist.
Vulvar Paget’s disease.
This generally arises from skin stem cells in the hair follicles, but can come from other sites. It can be confused with other dermatoses, so biopsy is necessary. The condition is rare (<1/100 000 people/year).
As a general rule, treatment is by surgical excision but in very special cases Imiquimod cream might be considered after discussion with a Gynaecologic Oncologist.
In a small number of women, the Paget’s disease may have come from an adenocarcinoma elsewhere in the body, so the doctor may search for these with further investigations.
Melanoma in situ.
This is only rarely seen on the vulva. Vulval melanoma accounts for only 3% of all melanomas, and <10% of all vulval malignancies.
Diagnosis is made by biopsy of suspicious pigmented lesions.
Prevention of Vulval Malignancies.
Most vulval pre cancers are HPV related, and vaccination with a 9 valent HPV vaccine (Gardasil-9) in young women is proven to prevent the development of these lesions.
Vaccination after diagnosis of HPV related lesions in previously unvaccinated individuals might be beneficial and is currently the subject of ongoing studies.
Reduction of the incidence of dangerous dVIN lesions in women with vulvar Lichen Sclerosus can be achieved by regular specialist skin review and compliance with the use of potent topical steroid treatments. Even women with no symptoms should continue regular weekly applications of treatments and be seen every 6 to 12 months by an appropriately trained health care provider for life.
Image borrowed from well-woman.org
Cervical polyps are small lumps that protrude from the mucous lining of the cervix. They are almost always benign, but occasionally can be precancerous, or very rarely, cancers.
Often completely asymptomatic and noted at your CST, they sometimes cause bleeding after intercourse, or between periods, or a mucous discharge. They can usually be removed painlessly in the office.
Image borrowed from medcell.med.yale.edu
1. Skin like "squamous" cells
2. Mucous secreting cells, sometimes known as an ectropian
3. Vaginal wall. Note how it is folded, so that it can expand during child birth.
4. "Squamocolumnar junction".
This is defines the edge of where most pre cancers and cancers form, and can be inside the cervix in older women, making full diagnosis more difficult.
Bathing the cervix in a weak solution of acetic acid (vinegar) causes cells that are growing more quickly than usual to turn white.
This directs our attention to the areas that need a biopsy.
The pathologist then takes the biopsy, and is able to report on whether the changes are normal, low grade, or high grade.
Your gynaecologist can then report back to you whether treatment is required, or, in the case of low grade change, whether a "wait and see" approach is appropriate.
Most low grade changes will resolve with patience. A small number can become high grade, so follow up is essential.
Frequently Asked Questions about HPV virus and pre cancer
(answers sourced from the National Cervical Screening Programme website)
How did I get HPV?
HPV virus is sexually acquired and 80% of infections are short lived. Most sexually active people will get HPV infections, and 46% of individuals will get HPV within 3 years of commencing sexual activity. Fortunately, cancer is a rare outcome, particularly amongst women who are regularly screened.
How effective is the HPV vaccine?
Gardasil9 is 97% effective in protecting recipients against the types of virus that cause 90% of cervical cancers. You can read more information about it here.
What diseases in humans are caused by HPV?
HPV infections have been implicated in:
99.7% of cervix cancers
90% of anal cancers
40% of vulval, vaginal, and penile cancers
12% of mouth and throat cancers
It can take up to 15 years for cancers to develop in people with persistent HPV infections. This gives health providers an opportunity to screen people at intervals before a cancer develops.
But I'm over 50, surely I'm not going to get HPV now, right?
Wrong. Studies have shown that 21% of women who were negative for HPV testing at baseline age of 51 had acquired HPV on testing 3 years later.
Furthermore, older women were less likely to get rid of the virus naturally than younger women.
How does HPV cause precancerous cells?
HPV viruses need to use the protein factories inside cells to reproduce themselves, and to do this they inject their DNA into a healthy cell's DNA to trick it into making more viruses.
Unfortunately, sometimes this process can also switch on genes inside the host cell that cause the cell to start growing in an uncontrolled fashion. This is called neoplasia. If the changed cells are only growing in the superficial skin layers it is called pre-invasive disease.
Pre-invasive disease can be treated by simple treatments to remove the cells without having to remove the cervix and body of the uterus.
Pre-invasive disease also tends to be asymptomatic, which is why screening for the presence of high risk virus is important. By the time women start to develop symptoms such as bleeding after sex, there is an increased risk that the disease has become invasive cancer, which usually requires more major surgery that can destroy fertility.
Not all bleeding after sex is due to pre cancer. That's why it needs to be investigated by colposcopy before any treatment is instituted, to rule out benign causes.
What's the difference between "low grade" and "high grade" lesions?
Low grade lesions are evidence that there is HPV infection present, but decades of scientific study have identified that most of these lesions will disappear as the body naturally clears the virus.
High grade lesions have a higher chance of eventually developing into invasive cancers. High grade lesions include CIN 2 and CIN 3.
If CIN 2 is not treated, about 5% (1 in 20 patients) will develop invasive cancer.
If CIN 3 is not treated, up to 30% (1 in 3 patients) will develop invasive cancer within 5-10 years.
These elevated risks in these populations explains the policy to treat these high grade lesions in all patients who have them, especially because we have no way of identifying which women with CIN2/3 will ultimately go on to get invasive cancer.
In addition, long term follow studies in Australia have demonstrated that women treated for high grade lesions have very low risks of recurrence; in fact a study showed that none of these patients developed subsequent cancers if properly followed up.
How much tissue needs to be removed from the cervix during treatment?
This depends on the size of the lesion, the type of abnormal cells, and whether they are seen going up inside the cervix at colposcopy.
Many cases will only require less than 10-15 mm of tissue removal. Bear in mind that the cervix is generally 30-40 mm long.
Occasionally for cases where the lesion is inside the cervix a cone biopsy will be required. This is similar to an "apple coring" procedure.
In a small number of cases the pathologic examination of the removed tissue might indicate that the abnormal cells extend to the margin of excision and a further treatment might be necessary.
This is because the risk of recurrence in women who have incomplete excision is 18%, compared to a 3% risk of recurrence in women who had complete excision.
After I am successfully treated, what is my risk of getting another high grade lesion?
A study in 2006 showed that after 22 years follow up, 8.5% of women who had been treated for high grade lesions had a recurrence.
Twenty percent (20%) of these new lesions developed after 2 years.
This is why close follow up early after treatment, and then ongoing as for other women, is necessary.
Does treatment of high grade lesions affect fertility?
Treatment appears to have very little if any affect on subsequent fertility.
Does treatment of high grade lesions have any risks for subsequent pregnancy?
The risk of subsequent pre term birth and low birth weight in women who have been treated for high grade lesions appears to be related to the type of treatment and the amount of tissue removed.
"Cold knife" cone biopsy appears to at least double the risk of preterm birth.
LLETZ procedures seem to carry less risk, and a 2008 study found no significant risk of serious adverse pregnancy outcomes.
However, all women who have had treatment of cervical pre-cancerous lesions must inform their pregnancy caregivers about this, and it would be considered standard practice to monitor the length of the cervix by ultrasound during the pregnancy.
Most women will have normal pregnancy outcomes.
Importantly studies have shown that women who did not have treatment for their high grade lesions have also been shown to an increased risk of pre term birth.
Is there anyway I can get rid of the virus, or prevent myself getting more precancerous lesions in the future?
Unfortunately there are no medicines or natural therapies that have been shown to be beneficial at removing the virus. Smoking is an important risk factor for precancers, so should be stopped.
Currently there have been a number of trials that have shown that vaccination of individuals with high grade lesions might help prevent recurrence of precancers, but unfortunately the data are inconclusive at present.
There is a large randomised controlled trial which is currently ongoing ( the NOVEL trial) which is examining the role of Gardasil9 vaccination after treatment for high grade lesions which it is hoped will report on the cost effectiveness of such a strategy.