Cervical screening (HPV)

Specialties > Gynaecology

Background knowledge 🧠

Definition

Cervical screening involves testing for high-risk human papillomavirus (HPV) infection, which is a major risk factor for cervical cancer.
The screening programme aims to detect pre-cancerous changes, enabling early intervention to prevent progression to cervical cancer.
Screening is offered to women aged 25-64 in the UK.
HPV testing is now the primary screening method in the UK.

Epidemiology

Cervical cancer is the 14th most common cancer in women in the UK.
HPV is implicated in over 99% of cervical cancer cases.
HPV 16 and 18 are responsible for approximately 70% of cervical cancer cases.
Cervical screening has significantly reduced the incidence and mortality of cervical cancer in the UK.

Aetiology and Pathophysiology

Persistent infection with high-risk HPV types leads to the development of cervical intraepithelial neoplasia (CIN).
CIN can progress to cervical cancer if not detected and treated early.
HPV is transmitted through sexual contact.
Risk factors for persistent HPV infection include smoking, immunosuppression, and multiple sexual partners.

Types of HPV

HPV strains are classified into high-risk (oncogenic) and low-risk (non-oncogenic) types.
High-risk types include HPV 16, 18, 31, 33, 45, 52, and 58.
Low-risk types (e.g., HPV 6 and 11) are associated with genital warts but not cancer.
HPV 16 and 18 are the most common high-risk types detected in cervical cancer.

Clinical Features 🌡️

Symptoms

Early stages of cervical cancer are often asymptomatic.
Symptoms may include abnormal vaginal bleeding, such as postcoital, intermenstrual, or postmenopausal bleeding.
Other symptoms include unusual vaginal discharge and pelvic pain.
Advanced stages may present with symptoms like weight loss, fatigue, and lower back pain.

Signs

On speculum examination, there may be visible cervical lesions or ulceration.
Enlarged pelvic lymph nodes may be palpable in advanced disease.
Advanced cervical cancer may present with a fixed or immobile cervix due to local invasion.
Bimanual examination may reveal a bulky or irregularly shaped cervix.

Investigations 🧪

Tests

HPV primary screening is the first step; if positive, cytology (Pap test) is performed to detect abnormal cells.
Colposcopy is indicated if cytology results show high-grade abnormalities.
Biopsy during colposcopy can confirm the presence and severity of CIN or cervical cancer.
Further imaging (e.g., MRI, CT) may be used for staging if cancer is diagnosed.

Management 🥼

Management

Treatment of CIN involves excisional procedures such as LLETZ or cone biopsy.
Early-stage cervical cancer may be treated with surgery (e.g., hysterectomy) or radiotherapy.
Advanced cervical cancer is managed with a combination of chemotherapy, radiotherapy, and surgery.
Regular follow-up with HPV testing is essential post-treatment to monitor for recurrence.

Complications

Potential complications include infertility, fistula formation, and chronic pelvic pain post-treatment.
Lymphoedema may occur following lymph node dissection.
Radiotherapy may lead to bowel and bladder complications.
Psychosocial impacts, such as anxiety and depression, are common and require holistic management.

Prognosis

Prognosis is good for early-stage cervical cancer, with a 5-year survival rate of over 90%.
Survival decreases with more advanced stages, emphasizing the importance of early detection through screening.
Regular follow-up is crucial for detecting recurrences early.
HPV vaccination has the potential to significantly reduce the incidence of cervical cancer in the future.

Key Points

Cervical screening aims to detect high-risk HPV and prevent cervical cancer through early intervention.
HPV vaccination is a key preventive measure against cervical cancer.
Regular follow-up and compliance with screening guidelines are essential for prevention and early detection.
Management strategies are stage-dependent and may include surgery, radiotherapy, and chemotherapy.
Prognosis is excellent for early-stage disease, highlighting the importance of regular screening.

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