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

Cervical cancer is a malignant tumour arising from the cervix (lower part of the uterus that connects to the vagina). It is the 4th most common cancer in women globally, with 660,000 new cases and 350,000 deaths annually — 90% of deaths occurring in low- and middle-income countries. Nearly all cervical cancers (99.7%) are caused by persistent infection with high-risk human papillomavirus (HPV). Squamous cell carcinoma (70%) and adenocarcinoma (25%) are the two main histological types. The WHO targets global elimination of cervical cancer through HPV vaccination, screening, and treatment access. WHO global data show that the 5-year survival of localised cervical cancer (Stage I) is 91-93%, falling to 16-19% for Stage IV disease — demonstrating the immense importance of early detection through regular cervical screening and HPV vaccination before cancer develops. Adenocarcinoma of the cervix is increasing in proportion, is harder to detect by cytology, and is more commonly associated with HPV 18 — making HPV primary screening more effective than cytology alone for early detection of glandular lesions.

The primary cause is persistent infection with high-risk HPV strains — HPV 16 and 18 account for 70% of all cervical cancers. Most HPV infections are cleared by the immune system within 1-2 years, but persistent high-risk HPV infection causes precancerous changes (CIN — cervical intraepithelial neoplasia) that progress to cancer over 10-20 years. Additional risk factors: multiple sexual partners or early sexual debut (increases HPV exposure), immunosuppression (HIV-positive women have 6x higher risk), smoking (impairs local immune clearance of HPV), co-infection with other STIs (chlamydia, herpes), high parity (multiple pregnancies), and long-term oral contraceptive use. HPV 16 is associated predominantly with squamous cell carcinoma; HPV 18 with adenocarcinoma. Together these two serotypes account for 70% of all cervical cancers. HIV-positive women have a 6-fold elevated risk from impaired local HPV clearance and more rapid CIN progression.

Early-stage cervical cancer and CIN (precancer) are typically asymptomatic — detected through cervical screening. Symptoms of invasive disease include: intermenstrual bleeding (bleeding between periods), post-coital bleeding (bleeding after sexual intercourse — the most common presentation), post-menopausal bleeding, offensive vaginal discharge (blood-stained or foul-smelling), and pelvic pain or pressure. Advanced disease symptoms: unilateral leg swelling (lymph node obstruction), back or flank pain (ureteric obstruction), haematuria or rectal bleeding (bladder or rectal invasion), and constitutional symptoms (weight loss, fatigue, anorexia). Any post-coital bleeding or unexplained vaginal bleeding requires prompt medical assessment. Watery, foul-smelling, or blood-stained vaginal discharge from cervical cancer may be initially attributed to infection — any vaginal discharge not responding to standard antibiotics requires colposcopy and cervical examination to exclude cervical pathology. Pelvic discomfort during intercourse (dyspareunia) may indicate parametrial invasion in more advanced disease.

Screening: cervical cytology (Pap smear) detects abnormal cells; HPV primary screening (testing for high-risk HPV DNA) has largely replaced or augments cytology in many countries due to higher sensitivity. Colposcopy (direct visualisation of the cervix with magnification and acetic acid/iodine staining) and directed biopsies diagnose CIN and early cancer. Staging is clinical and imaging-based (FIGO 2018 staging): MRI pelvis (best for local staging), CT chest/abdomen/pelvis (nodal and distant metastasis), PET-CT (lymph node assessment). Examination under anaesthesia (EUA) for clinical staging in advanced disease. Squamous cell carcinoma antigen (SCC-Ag) is a tumour marker useful for monitoring. Fertility-sparing staging in young women with early-stage cervical cancer includes MRI to confirm tumour size below 2 cm and no parametrial involvement before offering radical trachelectomy. Sentinel lymph node mapping using ICG (indocyanine green) is increasingly used in early-stage cervical cancer to reduce the extent of lymphadenectomy.

Precancerous lesions (CIN): CIN 2-3 is treated with LLETZ (large loop excision of the transformation zone) or cone biopsy — removes the precancerous area and allows histological assessment. Early-stage invasive cancer (Stage IA-IB1): radical hysterectomy (removes uterus, parametria, upper vagina, and pelvic lymph nodes) with excellent 5-year survival (85-92%); trachelectomy (cervix removal preserving the uterus) for fertility-preserving surgery in selected Stage IA-IB1 patients. Locally advanced disease (Stage IB2-IVA): concurrent chemoradiotherapy (EBRT + brachytherapy + cisplatin-based chemotherapy) is the standard of care — 5-year survival 60-80% for Stage II, 30-50% for Stage III. Metastatic/recurrent disease: cisplatin + paclitaxel + bevacizumab (+ pembrolizumab if PD-L1-positive, per KEYNOTE-826) extends survival. Cemiplimab monotherapy for PD-L1-positive recurrent disease. Fertility-preserving radical trachelectomy (removal of cervix, upper vagina, and parametria while preserving the uterine body) achieves oncological outcomes equivalent to radical hysterectomy for Stage IA2-IB1 tumours below 2 cm — with successful pregnancy rates of 40-70% in appropriately selected young women. Tisotumab vedotin (antibody-drug conjugate targeting tissue factor) demonstrated improved overall survival in recurrent metastatic cervical cancer in the innovaTV 301 trial.

Untreated CIN 3 has a 30-50% risk of progressing to invasive cervical cancer over 10 years without treatment. Invasive cancer invades locally into the bladder, rectum, pelvic sidewall, and ureters, causing ureteric obstruction and renal failure — a common cause of death in advanced untreated disease. Lymph node and distant metastases (lung, liver, bone) develop in advanced stages. Vaginal fistulae (abnormal connections between vagina and bladder or rectum) can occur from tumour invasion. Uncontrolled haemorrhage from tumour necrosis is a palliative emergency. Globally, cervical cancer deaths are largely preventable — representing a profound failure of vaccination and screening access.

HPV vaccination: highly effective against HPV 16 and 18 (and additional strains in the 9-valent Gardasil-9 vaccine). Best given before sexual debut, recommended at age 11-12 years for girls and boys in most national programmes. Vaccination reduces cervical cancer risk by over 90% for vaccinated serotypes. Catch-up vaccination is offered up to age 26 (and up to age 45 in some guidelines). Regular cervical screening: Pap smear every 3 years (age 25-64 in UK); HPV primary testing every 5 years; more frequent if abnormal results. Practice safer sex (condoms reduce but do not eliminate HPV transmission). Stop smoking. In women who have had hysterectomy for CIN/cancer, individualised follow-up is required as vaginal vault vault smears are needed.

See your GP urgently for: any episode of post-coital bleeding (bleeding after sexual intercourse) that is not explained — this is the most common presenting symptom of cervical cancer and requires prompt assessment including cervical examination; post-menopausal vaginal bleeding — always requires urgent investigation to exclude gynaecological malignancy; intermenstrual bleeding (bleeding between periods) that is persistent or heavy and unexplained by contraception; offensive or blood-stained vaginal discharge not explained by infection; pelvic pain that is new or progressively worsening. Attend Emergency Department for: heavy vaginal bleeding from known or suspected cervical cancer — may require emergency treatment (gauze packing, radiotherapy, embolisation). Following an abnormal smear: attend all colposcopy appointments promptly — delays increase risk of precancer progressing to invasive cancer; do not delay LLETZ treatment if recommended. Ensure you are registered for cervical screening — in the UK, all women and people with a cervix aged 25-64 are entitled to free NHS cervical screening.