Cervical Cancer — Causes, Symptoms & Treatment Guide — Symptoms, Causes & Treatment | MyMedicPlus

Cervical cancer is a malignant tumour of the cervix uteri, arising in the transformation zone where ectocervical squamous epithelium meets endocervical columnar epithelium. It is the 4th most common cancer in women globally, with approximately 660,000 new cases and 350,000 deaths per year. Over 90% of deaths occur in low- and middle-income countries where screening and vaccination programmes are limited. Virtually all (99.7%) cervical cancers are caused by persistent infection with high-risk human papillomavirus (HPV) types — predominantly HPV-16 (most oncogenic) and HPV-18, together accounting for 70% of cases. Squamous cell carcinoma accounts for 70-80% of cervical cancers; adenocarcinoma accounts for 20-25%. The WHO's 90-70-90 elimination strategy targets 90% HPV vaccination of girls by age 15, 70% of women screened twice before age 45, and 90% of women identified with disease receiving treatment — an achievable global public health goal by 2030.

Persistent high-risk HPV infection is the necessary cause of cervical cancer. HPV types 16, 18, 31, 33, 45, 52, and 58 are classified as high-risk oncogenic strains. HPV is sexually transmitted and is extremely common — most sexually active individuals are infected at some point, but the vast majority clear the virus spontaneously. Risk factors for persistent HPV infection and malignant progression: early sexual debut, multiple sexual partners, immunosuppression (HIV infection increases cervical cancer risk 5-fold; organ transplant recipients), long-term oral contraceptive use (>5 years), smoking (impairs local cervical immunity), failure to participate in screening, high parity, co-infection with other sexually transmitted infections (chlamydia), and low socioeconomic status limiting screening access.

Early cervical cancer (and precancerous stages — CIN 1-3) is usually completely asymptomatic, detectable only by screening. As the cancer becomes clinically apparent: abnormal vaginal bleeding (most common presenting symptom) — intermenstrual bleeding, postcoital bleeding (bleeding after sexual intercourse), or postmenopausal bleeding; abnormal vaginal discharge (watery, blood-tinged, or malodorous); pelvic pain. Advanced disease: ureteric obstruction causing renal impairment or hydronephrosis, bladder (haematuria, urinary frequency) and rectal (rectal bleeding, altered bowel habit) involvement from local extension, leg oedema from lymphatic obstruction, and sciatic nerve pain from pelvic sidewall extension. Distant metastases (lung, bone, liver) cause systemic features in stage IVB disease.

Histological confirmation by cervical biopsy is required for diagnosis. Colposcopy (magnified examination of the cervix with acetic acid and Lugol's iodine application) guides targeted biopsies of suspicious areas. Loop excision of the transformation zone (LLETZ/LEEP) is both diagnostic and therapeutic for high-grade CIN. FIGO 2018 clinical staging determines treatment: based on clinical examination, imaging (MRI pelvis for local extent, CT thorax-abdomen-pelvis or PET-CT for lymph node and distant metastasis assessment), and where available pathological nodal assessment. MRI pelvis is the most accurate modality for assessing tumour size, parametrial invasion, and bladder/rectal involvement. Cystoscopy and proctoscopy confirm bladder/rectal involvement. HPV genotyping and p16/Ki-67 immunostaining support pathological assessment.

Stage IA1 (microinvasion, no LVSI): cold knife cone biopsy or LLETZ with clear margins in women wishing to preserve fertility; simple hysterectomy otherwise. Stage IA2-IIA (early localized disease): radical hysterectomy (removal of uterus, parametria, upper vagina, and pelvic lymph node dissection) OR definitive chemoradiotherapy — both are equivalent in outcome for Stage IB1-IIA. Stage IIB-IVA (locally advanced): concurrent chemoradiotherapy is standard — external beam pelvic radiotherapy + weekly cisplatin chemotherapy + intracavitary brachytherapy boost to the cervix. Brachytherapy achieves high local control rates (>85% for IIB). Stage IVB/recurrent/metastatic: pembrolizumab (anti-PD-1) + chemotherapy (cisplatin/carboplatin + paclitaxel) ± bevacizumab (anti-VEGF) — pembrolizumab combination is now standard first-line for recurrent or metastatic disease (KEYNOTE-826 trial). Sentinel lymph node biopsy is increasingly used in early disease to reduce lymphoedema from full lymphadenectomy.

Cervical cancer invades locally into the bladder (haematuria, vesicovaginal fistulae), rectum (rectal bleeding, rectovaginal fistulae), and ureters (ureteric obstruction causing renal failure — a common cause of death in advanced untreated disease). Untreated CIN 3 (high-grade precancer) has a 30-50% risk of progressing to invasive cancer over 10 years. Lymphatic obstruction from nodal disease causes leg oedema and deep vein thrombosis. Para-aortic lymph node spread is associated with 5-year survival below 20%. Haemorrhage from tumour necrosis can be life-threatening, requiring emergency radiotherapy or embolisation. Globally, cervical cancer deaths largely represent a failure of vaccination and screening access — the WHO targets elimination through achieving 90% HPV vaccination, 70% screening coverage, and 90% treatment coverage by 2030.

HPV vaccination is the primary prevention strategy. Gardasil 9 (nonavalent) vaccine protects against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58, covering approximately 90% of cervical cancer-causing strains. Recommended for girls and boys aged 9-14 before sexual debut; catch-up vaccination up to age 26 (or 45 in certain cases). Two doses suffice before age 15; three doses are required after. Secondary prevention: cervical screening with HPV co-testing or liquid-based cytology (Pap smear) as per national guidelines (typically every 3-5 years from age 25). Colposcopy referral for HPV-positive or abnormal cytology results. Treat high-grade CIN (CIN 2-3) with LLETZ to prevent progression to invasive cancer. Quit smoking — smoking contributes to cervical carcinogenesis and impairs treatment response. Condom use reduces (but does not eliminate) HPV transmission risk.

Seek urgent medical attention for any postcoital bleeding (bleeding after sexual intercourse), intermenstrual bleeding, or postmenopausal vaginal bleeding — these require prompt gynaecological evaluation including speculum examination and colposcopy referral. Any visible lesion or abnormality on the cervix identified by a healthcare provider requires urgent colposcopy and biopsy. Cervical screening appointments should never be missed — the long precancerous phase (CIN 1-3 over 10-15 years before invasion) makes early detection and treatment highly effective. Women with HPV-positive or inadequate smear results must attend colposcopy referral without delay. Women who have had total hysterectomy for CIN or cervical cancer still require individualised follow-up with vault smears — do not assume screening is no longer needed after surgery.