GYNAECOLOGICAL HISTORY

Gynaecological History and
Examination This should be handled with sensitivity
and preservation of dignity for the
patient. NB: always consider the possibility of pregnancy when presented with
abnormal bleeding or pain. History Presenting complaint Allow the patient to tell you her problem.
She may need prompting over more
delicate issues, especially if you are a
man. Menstrual history: Last menstrual period (LMP) - date of first
day of bleeding. Cycle length and frequency, e.g. 5/28, 5
days of bleeding every 28 days. How heavy is the bleeding? Number of
tampons per day/clots/flooding/double
protection. Any intermenstrual bleeding (IMB). Any postcoital bleeding (PCB). Age of menarche/menopause. Any postmenopausal bleeding (PMB). Discharge: Colour. Amount. Smell. Itchiness. Duration. Rash. Any symptoms in a partner. Pain or discomfort: Duration, type, alleviating or aggravating
factors, radiation. Any relation to cycle (mid-cycle or
period-related). Any possibility of pregnancy (ectopic). Bowel problems. A feeling of "something coming down
below" may be a prolapse. Dyspareunia - superficial or deep. Urinary symptoms: Leakage. Cloudiness. Haematuria. Hesitancy. Dysuria. Frequency. Stranguary. Stress or urge incontinence. Obstetric history: Number of children, details of pregnancy, labour and delivery, birthweights. Any problems with the babies. Miscarriages/terminations. Any postnatal problems, e.g. depression. Conception difficulties/subfertility. Contraception: Contraceptive history. Any recent unprotected intercourse. Reliability of method and user. Potential contra-indications to different
methods, e.g. combined pill. Permanent or temporary method
required. Sex/relationships: Sexually active. Sexual orientation. Relationship difficulties - ask open-ended
questions, e.g. "How are things between
you?" Infection: Any past history of pelvic inflammatory disease. Was it adequately treated, including
contact tracing. Any known contact with sexually transmitted diseases. Asses the risk of HIV and hepatitis. General health: Smoking/alcohol/drugs (especially
intravenous usage). Note any other health symptoms or
concerns, e.g. arthritis, physical mobility
problems, any breast symptoms (such as
breast tenderness, discharges, lumps),
history of breast cancer, etc; acne, hirsutism, abnormal weight gain or loss,
etc. Gynaecological operations. Date and result of last cervical smear. Examination Allow privacy to undress. Offer a
chaperone for the examination, and
record its offer in notes (together with
whether the offer was taken up or
declined). Always use a chaperone if
requested and especially if your sixth sense tells you to. Provide a blanket or
other clean cover. Explain what you are
doing and why before you do it, rather
than as you do it. General appearance: Paleness. Jaundice. Smoke-stained fingers. Obesity. Extreme thinness. Swollen abdomen. Ankle swelling. Look for pyrexia, shock, swelling. Blood pressure, breast examination (if
appropriate). Abdomen palpation feeling for: Peritonitis. Abnormal lumps including enlarged
uterus, liver, spleen, nodes in the groin
and umbilicus. Ascites, distended veins - peritoneal secondaries can show with an umbilical
secondary. Percuss the bladder if palpably enlarged,
or indicated from history. Vaginal examination Usually done with the patient on her
back. Look at the vulva for any abnormalities
of skin texture, lumps, excoriation,
lichenification and whitening. Choose an appropriately sized speculum -
usually Cusco's bivalve speculum - for the
patient. Warm the speculum before use. Part the labia with your hand from above
and introduce the speculum at a slight tilt
to the vertical and twist it gently to the
horizontal. Point the speculum downwards, at about
45°; open, making sure that the handle is
not impinging on the clitoris. Look at the vaginal mucosa and locate
the cervix. Take a vaginal swab if there is discharge. Check for any retained tampon. Look for warts/herpes (the rash may give symptoms for a week or so before
the vesicles appear). If no cervix visualised : Try partially withdrawing and try again. Perform a bimanual examination to
establish the position of the cervix. Ask the patient to hold on to her knees or
put hands under the sacrum to tilt the
pelvis. A pillow could also be used. The left lateral position may be more
successful. If you are still unsuccessful, try on a
different occasion. Taking a smear Ideally, this should take place mid-cycle. Visualise the cervix, clear excess mucus/
discharge, unless using liquid-based
cytology (LBC). If using a spatula, make two full 360°
sweeps of the cervix to sample the
transformation zone. Fix the slide
immediately, as drying before fixing
spoils the smear. If there is an obviously abnormal area on
the cervix, note the position on the form/
notes and include the area in your smear
sweep. If using a brush and LBC, take 5
anticlockwise sweeps of the
transformation zone. Then (depending on
the brush type) either push the end of the
brush into the liquid, or agitate the brush
in the liquid for 15-20 seconds to ensure there are adequate cells in the specimen.
LBC has reduced the rate of inadequate
smears. Training is provided locally. Take care not to pinch the vaginal wall or
even the cervix when withdrawing the
speculum. Remember to note your findings on the
request form. Results are sent directly to the patient's
address. Colposcopy may be arranged directly if necessary. Mention the possibility of needing to redo
the smear or examine more closely
(colposcopy). Bimanual examination Use your left hand to palpate abdomen
and your right for internal (if examining
from the right). Feel for any abnormalities of the vagina. Feel the cervix for areas of roughness,
hardness, lumps. Note any cervical
excitation. Assess the uterine position, size,
mobility, lumpiness, tenderness. Feel the adnexae bimanually for any
swelling or tenderness. NB: an ectopic pregnancy can be ruptured by bimanual examination, so be
gentle. Uterine size: Within the pelvis (size of an orange) = 8
weeks. Suprapubic = 12 weeks. Mid-suprapubic umbilicus = 16 weeks. To umbilicus = 20 weeks. To xiphisternum = 36 weeks. NB: the height drops as the fetal head engages into the pelvis at term. Urinary incontinence Confirmation of leakage can be done by
asking the patient to cough whilst
holding a tissue over the urethral
opening, either lying or standing with the
feet slightly apart.
However, if there is a history of urinary incontinence then refer for urodynamics. Prolapse Vaginal examination needs to be
performed with a Sims' speculum in the
left lateral position looking for a cystocele or rectocele. An assistant can hold the leg at 30°
(useful if the patient is obese). You need to have a good light and look
for uterine or vaginal prolapse whilst withdrawing the Sims' speculum....Intermenstrual and Postcoital
Bleeding Intermenstrual bleeding refers to vaginal bleeding (other than postcoital)
at any time during the menstrual cycle
other than during normal menstruation. It
can sometimes be difficult to
differentiate true intermenstrual
bleeding from metrorrhagia (irregularly frequent periods). Postcoital bleeding is non-menstrual bleeding that occurs immediately after
sexual intercourse. Both are symptoms, rather than
diagnoses, and warrant further
assessment. They occur commonly and
are emphasised in referral guidelines for
suspected gynaecological cancers. Whilst
genital tract malignancy is an uncommon cause of bleeding and a rare cause in
young women, it must be considered in
all patients. Epidemiology Self-reported intermenstrual bleeding
(IMB) and postcoital bleeding (PCB) have
an annual cumulative incidence of 17%
and 6% respectively in menstruating
women from a questionnaire study based
on subjects within an urban English, general practice setting.1 PCB occurs in 0.7-39% of women with cervical cancer. The risk of a woman seen in the community with PCB having
cervical cancer is approximately 1 in
44,000 in 20-24 year olds and 1 in 2,400 in 45-54 year olds.2 In another English study, looking at
pathological findings from a group of
women referred to colposcopy for PCB
but with a negative previous cervical smear, a third had an ectropion, 12% had cervical polyps, 7% had cervical
intraepithelial neoplasia (CIN), 2% had
chlamydia but nobody in this study had invasive cancer. 3 Only 2% of endometrial cancers occur
before 40 years old. Risk factors for endometrial cancer include: nulliparity, diabetes, obesity, polycystic ovary syndrome, unopposed oestrogen therapy, chronic anovulatory cycles and the use of
tamoxifen. Women with risk factors and
IMB should be fully investigated. Aetiology4 Causes of postcoital bleeding (PCB) Infection Cervical or endometrial polyps Vaginal cancer Cervical cancer Trauma Causes of intermenstrual bleeding (IMB) Pregnancy-related including ectopic pregnancy and gestational trophoblastic disease Physiological - 1-2% spot around
ovulation Iatrogenic Combined oral contraceptive pill (COCP) - either in too low dose or in combination
with an enzyme-inducing drug Progesterone-only pill Contraceptive depot injections Intrauterine systems (IUS)5 or implant Emergency contraception6 Tamoxifen Following smear or treatment to the
cervix Caesarean section scars7 Drugs altering clotting parameters, e.g.
anticoagulants, SSRIs, corticosteroids Alternative remedies, e.g. ginseng,
ginkgo, soy supplements, and St John's wort8 Vaginal causes: Adenosis Vaginitis (bleeding uncommon before the menopause) Tumours Cervical causes: Infection - chlamydia, gonorrhoea Cancer (but bleeding is most often
postcoital) Cervical polyps Cervical ectropion Condylomata acuminata of the cervix Uterine causes: Endometrial polyps Cancer (endometrial adenocarcinoma, adenosarcoma9 and leiomyosarcoma) Adenomyosis (usually only symptomatic in later reproductive years) Endometritis Fibroids Oestrogen-secreting ovarian cancers Presentation Given the wide differential for non-
menstrual vaginal bleeding, a careful
history and examination is paramount. History Menstrual history: Last menstrual period - was the last
period a 'normal' period? Regularity and cycle length Duration of abnormal bleeding -
prolonged versus recent change? Presence of menorrhagia Timing of bleeding in the menstrual cycle Associated symptoms, e.g. abdominal
pain, fever, vaginal discharge,
dyspareunia, Factors that aggravate bleeding, e.g.
exercise, intercourse Obstetric history Previous pregnancies and deliveries,
including time since last delivery/
miscarriage/termination Current breast-feeding Risk of current pregnancy - increased, for
example, with unprotected intercourse,
forgotten pills, gastroenteritis or
antibiotics used with the COCP Risk factors for ectopic pregnancy - for
example, a history of pelvic inflammatory
disease or endometriosis, IVF treatment,
use of an intrauterine contraceptive device (IUCD) or the progestogen-only pill (POP) Gynaecological history: Current use of contraception Smears - most recent test results, any
previous smear abnormalities,
colposcopy, treatment for abnormalities,
etc. Previous gynaecological investigations or
surgery Sexual history - risk factors for sexually transmitted infection (STI) (those aged
<25 years, or at any age with a new partner, or more than one partner in the last year), past history and treatment for STIs. Medical history - e.g. bleeding disorders, diabetes Current medication (including unprescribed) Examination Establish that the bleeding is from the vagina, not the rectum or in the urine. Any doubt can be eliminated by inserting a tampon which will confirm presence of blood in the vagina. BMI - high BMI is an independent risk factor for endometrial cancer. Abdominal examination noting the presence/absence of pelvic masses. PV examination (speculum and bimanual) looking for obvious genital tract pathology. Note whether any contact bleeding occurs, friability of tissue, cervical 'excitation' or tenderness, presence of ulceration, polyps or discharge and any other lower genital tract sites of bleeding. Common findings include:Cervical ectropion (or erosion) - appears as a red ring around the external os due to extension of the endocervical columnar epithelium over the ectocervix. Cervical polyp - mass arising from the endocervix, usually protruding through the external os into the vagina. They can be avulsed and sent to histology. Occasionally, endometrial polyps can be seen extruding through the cervix. In a Danish study, polyps were found in 5.8% of premenopausal women but only 9% of those under the age of 30 years.10 Cervicitis - the cervix appears red, congested and sometimes oedematous. There may be purulent discharge and the cervix is usually tender to palpation. The most common causes of infection currently is Chlamydia trachomatis. Neisseria gonorrhoeae as a cause of cervicitis should not be forgotten. A rarer cause is Trichomonas vaginalis where the cervix is friable, with prominent papillae and punctate haemorrhages, and is commonly described as a 'strawberry cervix'. Herpetic cervicitis gives rise to multiple ulcerated regions. Investigations Always exclude the possibility of pregnancy and STIs as a cause of bleeding:11 Pregnancy test - have a low threshold for checking and, if positive, urgent referral for ultrasound +/- serial serum β-HCG is needed to exclude ectopic pregnancy. Infection screen - always consider STIs, in particular chlamydia, with intermenstrual bleeding (IMB) and postcoital bleeding (PCB).12 A self- obtained low vaginal swab (SOLVS) can be offered (where available locally as part of the National Chlamydia Screening programme) or a first-void urine (FVU) if a speculum examination is not being performed. The decision to test for N. gonorrhoeae will depend on the woman's individual sexual risk and the local prevalence of this infection. In general, cervical smears should only be taken where a woman is due or overdue for her regular screening. Blood tests may include: FBC Clotting Thyroid function FSH/LH levels (if onset of menopause suspected) Referral for further investigation: With persistent IMB (usually taken as more than three months): Transvaginal ultrasound - this is the investigation of choice to look for structural abnormality. Ultrasound should ideally be done immediately postmenstrually as the endometrium at its thinnest and polyps and cystic areas tend to be more obvious. An endometrial thickness of 8 mm or less is significantly less likely to be associated with a malignant pathology.13 Evidence of endometrial thickening should prompt referral for biopsy. Even by an experienced operator, pathology can be missed on ultrasound in the presence of an IUCD due to reflections and shadowing.14 Endometrial biopsy may be done as a surgery or clinic-based procedure using the Pipelle® device or Vabra® aspirator.15 Their disadvantage is that they miss up to 18% of focal lesions. 4 Hysteroscopy with biopsy is the current gold standard for investigating the uterine cavity, allowing direct visualisation and tissue diagnosis.16 Who should be referred with persistent intermenstrual bleeding (IMB) and negative clinical findings for endometrial biopsy?11,17 Older women (>45 years) Women aged <45 years with risk factors
for endometrial cancer if IMB persists
after the first three months of starting a
contraceptive method or who present
with a change in bleeding pattern. For postcoital bleeding (PCB): Colposcopy - despite the low rate of
serious pathologies seen in referred PCB
cases with a negative recent smear,
there is a concern that these women are
nonetheless at an increased risk of CIN
and continue to warrant colposcopy referral.18 Management Management is dependent on the cause
of the bleeding. Suspected cancer If gynaecological cancer is suspected,
refer urgently for investigation. National Institute for Clinical Excellence guidelines suggest:19 A mandatory full pelvic examination,
including cervical speculum examination
for symptoms including intermenstrual
bleeding (IMB) and postcoital bleeding
(PCB). Where clinical features are suggestive of
cervical cancer on examination, urgent
referral of the patient. Do not wait for a smear result or delay
due to a previous negative smear result -
refer immediately where there is clinical
suspicion. Consider urgent referral for women with
persistent IMB but negative examination
findings. Infection Antibiotic treatment will depend on the
organism involved and local patterns of
sensitivity. Contact tracing and treatment of sexual
partners should be initiated. Electrocautery of secondarily infected Nabothian follicles is sometimes performed for chronic cervicitis. Hormonal contraception11 Warn women that unscheduled bleeding
in the first three months after starting a
new hormonal contraceptive method is
common, and that up to six months'
unscheduled bleeding with the IUS and
progestogen-only implant may be considered normal. Indeed the Royal
College of Obstetricians and
Gynaecologists' guidelines suggest that
genital examination is not required
within this time frame if, after taking a
clinical history, there are no risk factors for STIs or symptoms suggestive of other
underlying causes, and the woman is
participating in a National Cervical
Screening Programme. However, follow-up should be planned,
as bleeding may persist beyond this time. For persistent bleeding beyond the first
three months' use, or where there is a
change in bleeding pattern, or where a
woman has not participated in a National
Cervical Screening Programme, a
speculum +/- bimanual examination should be performed. Where clinical findings are normal, there
are no other associated symptoms, the
women is 45 years or under and has no
risk factors for endometrial cancer,
reassurance or medical treatment is
appropriate. Strategies for treating unscheduled
bleeding in those using hormonal
contraception: For COCP users: Stick with the same pill for a trial of at
least three months, as bleeding may
settle. Use a pill with a dose of ethinylestradiol
sufficient to provide the best cycle
control - consider increasing to a
maximum of 35 micrograms. May try a different COCP, or a different
dose or type of progestogen. For POP users: Try a different POP (although little
evidence that changing the progestogen
type or increasing the dose improves
bleeding) No evidence that desogestrel-only pills
(e.g. Cerazette®) have better bleeding
patterns than traditional POPs. No evidence that doubling to two pills
per day improves bleeding. For progestogen-only implants, depots
and IUS users: A first-line COCP (with 30-35 micrograms
ethinylestradiol) may be considered for
up to three months continuously or in the
usual cyclical regimen. Note this is an
unlicensed indication. There is no evidence that reducing the
injection interval for depot progestogen
injections improves bleeding but some
try bringing this forward by up to two
weeks. Mefenamic acid can be used to reduce the
duration of bleeding for women on depot
progestogen injections. Cervical ectropions These may resolve spontaneously if the
COCP is stopped, or following pregnancy They can be treated conservatively or
cauterised with silver nitrate. Other treatment options include thermal
cautery and diathermy, cryosurgery, laser or microwave therapy. 20 Cervical polyps Polyps should be avulsed and sent for
histology. They are accompanied by endometrial polyps in about 25%,21 so further investigation (ultrasound +/- hysteroscopy), particularly in older women, can be indicated..... The most common early symptom of
cervical cancer (cancer of the cervix) is
abnormal vaginal bleeding. Most cases
develop in women in their 30s or 40s. If
cervical cancer is diagnosed at an early
stage, there is a good chance of a cure. Regular cervical screening tests can
detect 'pre-cancer' which can be treated
before cancer develops. What is the cervix? The cervix is the lower part of the uterus
(womb) which extends slightly into the
top of the vagina. The cervix is often
called 'the neck of the womb'. A narrow passage called the cervical
canal (or endocervical canal) goes from
the vagina to the inside of the uterus.
This is normally kept quite tightly shut,
but allows blood to flow out from the
uterus during a period, and sperm to travel inside if you have sex. It opens
very wide during labour if you have a
baby. The surface of the cervix is covered
with skin-like cells. There are also some
tiny glands in the lining of cervical canal
which make mucus. What is cancer? Cancer is a disease of the cells in the
body. The body is made up from millions
of tiny cells. There are many different
types of cell in the body, and there are
many different types of cancer which
arise from different types of cell. What all types of cancer have in common is that
the cancer cells are abnormal and
multiply 'out of control'. A malignant tumour is a 'lump' or
'growth' of tissue made up from cancer
cells which continue to multiply.
Malignant tumours invade into nearby
tissues and organs which can cause
damage. Malignant tumours may also spread to
other parts of the body. This happens if
some cells break off from the first
(primary) tumour and are carried in the
bloodstream or lymph channels to other
parts of the body. These small groups of cells may then multiply to form
'secondary' tumours (metastases) in one
or more parts of the body. These
secondary tumours may then grow,
invade and damage nearby tissues, and
spread again. Some cancers are more serious than
others. Some are more easily treated
than others (particularly if diagnosed at
an early stage). Some have a better
outlook (prognosis) than others. So, cancer is not just one condition. In
each case it is important to know exactly
what type of cancer has developed, how
large it has become, and whether it has
spread. This will enable you to get
reliable information on treatment options and outlook. See separate leaflet called
'Cancer - What are Cancer and Tumours'
for further details about cancer in
general. What is cervical cancer? There are two main types of cervical
cancer: Squamous cell cervical cancer is the most common. This develops from a skin-like
cell (a squamous cell) that covers the
cervix which becomes cancerous. Adenocarcinoma cervical cancer is less common. This develops from a glandular
cell (a cell that makes mucus) within the
cervical canal which becomes cancerous. Both types are diagnosed and treated in a
similar way. Most cases develop in
women in their 30s or 40s. Some cases
develop in older and younger women.
However, it is rare in women under 25
years. Cervical cancer is the second most
common type of cancer in women in the
UK. It kills just over 1,000 women every
year in the UK. However, the number of
cases diagnosed each year has fallen over
recent years. This is because cervical cancer can be prevented by regular
cervical screening tests. What is the cervical screening test? Women in the UK are offered regular
cervical screening tests. During each test
some cells are taken from the surface of
the cervix. These cells are sent to the
laboratory to be looked at under a
microscope. In most tests the cells seen are normal. Dyskaryotic cells (cervical
dyskaryosis) are seen in some cases. Cervical dyskaryosis is not cervical
cancer. Cervical dyskaryosis means that
some cells of the cervix are abnormal, but
are not cancerous. The abnormal cells are
sometimes called 'pre-cancerous' cells or
dysplastic cells. Depending on the degree of the abnormality of the cells, cervical
dyskaryosis is classed as: Mild dyskaryosis. This is when there are
only slight cell changes. This is sometimes
called CIN 1. CIN stands for cervical
intraepithelial neoplasia. Moderate dyskaryosis (or CIN 2). Severe dyskaryosis (or CIN 3). This is
when the cells are very abnormal, but are
still not cancerous. In many cases the abnormal
(dyskaryotic) cells do not progress to
become cancerous. In some cases, they
revert back to normal. However, in some
cases, often years later, the abnormal
cells turn cancerous. If you have just slight abnormal changes
(mild dyskaryosis or CIN1), you may
simply be offered another test much
sooner than normal - after a few months
or so. In many cases, slightly abnormal
cells revert back to normal within a few months. Treatment may be offered if the
abnormality persists. For women with
moderate or severe abnormal changes,
treatment can clear the cervix of the
abnormal cells before they develop into cancer. See separate leaflet called 'Cervical
Screening Test' for more details. But the
'take-home message' is.... you are very
unlikely to develop cervical cancer,
IF...you have regular cervical screening
tests at the times advised by your doctor, AND ...you have treatment when advised
if abnormal cells are detected. What causes cervical cancer? A cancerous tumour starts from one cell.
It is thought that something damages or
alters certain genes in the cell. This
makes the cell very abnormal and
multiply 'out of control'. (See separate
leaflet called 'Cancer - What Causes Cancer' for more details.) In the case of cervical cancer, the cancer
develops from a cell which is already
abnormal - see above. In most cases,
abnormal cells are present for years
before one of the abnormal cells becomes
cancerous and starts to multiply out of control into a cancerous tumour. The
initial 'pre-cancerous' abnormality of
cervical cells is usually caused by a prior
infection with the human papilloma
virus. Human papilloma virus (HPV) and
cervical cancer There are many strains of HPV. Two
types, HPV 16 and 18, are involved in the
development of most cases of cervical
cancer. (Note: some other strains of HPV
cause common warts and verrucas. These
strains of HPV are not associated with cervical cancer.) The strains of HPV associated with
cervical cancer are nearly always passed
on by having sex with an infected person.
An infection with one of these strains of
HPV does not usually cause symptoms. So,
you cannot tell if you or the person you have sex with are infected with one of
these strains of HPV. In some women, the strains of HPV that
are associated with cervical cancer affect
the cells of the cervix. This makes them
more likely to become abnormal which
may later (usually years later) turn into
cancerous cells. Note: within two years, 9 out of 10 infections with HPV will clear
completely from the body. This means
that most women who are infected with
these strains of HPV do not develop
cancer. The HPV vaccine has recently been
introduced for girls from the age of 12 in
the UK. Studies have shown that the HPV
vaccine is very effective at stopping
cancer of the cervix developing. The
vaccine has been shown to work better for people who are given the vaccine
when they are younger, before they are
sexually active, compared to when it is
given to adults. However, even if you
have had the HPV vaccine you must attend for cervical screening. This is
because the vaccine does not guarantee
complete protection against cervical
cancer. See separate leaflet called 'HPV
Immunisation' for more detail. Other factors Other factors that increase the risk of
developing cervical cancer include the
following: Smoking. Chemicals from cigarettes get
into the bloodstream and can affect cells
throughout the body. Smokers are more
likely than non-smokers to develop
certain cancers, including cervical cancer.
In particular, if you smoke and have HPV infection, the risk is compounded. A poor immune system. For example,
people with AIDS or people taking
immunosuppressant medication have an
increased risk. (If your immune system is
not working fully then you are less able
to deal with HPV infection and abnormal cells and you are more at risk of
developing cervical cancer.) There is a possible link between the
combined oral contraceptive pill ("the
pill") and a slight increased risk of
cervical cancer if the pill is taken for
more than eight years. What are the symptoms of cervical
cancer? You may have no symptoms at first when
the tumour is small. As the tumour
becomes larger, in most cases the first
symptom to develop is abnormal vaginal
bleeding such as: Bleeding between normal periods
(intermenstrual bleeding). Bleeding after having sex (post coital
bleeding). Any vaginal bleeding in women past the
menopause. An early symptom in some cases is a
vaginal discharge that smells unpleasant,
or discomfort or pain during sex. All of the above symptoms can be caused
by various other common conditions. But
if you develop any of these symptoms,
you should have it checked out by a
doctor. In time, if the cancer spreads to other
parts of the body, various other
symptoms can develop. How is cervical cancer diagnosed and
assessed? To confirm the diagnosis A doctor will usually do a vaginal
examination if you have symptoms
which may possibly be cervical cancer. He
or she may feel an abnormal cervix. If
cervical cancer is suspected, you will
usually be referred for colposcopy. Colposcopy is a more detailed
examination of the cervix. For this test a
speculum is gently put into the vagina so
the cervix can be seen. The doctor uses a
magnifier (colposcope) to look at the
cervix in more detail. The test takes about 15 minutes. During colposcopy it is
usual to take a small piece of tissue from
the cervix (biopsy). The biopsy sample is
then examined under a microscope to
look for cancer cells. See separate leaflet
called 'Colposcopy' for more details. Assessing the extent and spread If you are found to have cervical cancer
then further tests may be advised to
assess if the cancer has spread. For
example, a CT scan, an MRI scan, a chest x-
ray, an ultrasound scan, blood tests or
other tests. (See separate leaflets called 'CT Scan', 'MRI Scan' and 'Ultrasound Scan'
for more details.) This assessment is
called 'staging' of the cancer. The aim of
staging is to find out: How much the tumour has grown, and
whether it has grown to other nearby
structures such as the bladder or rectum. Whether the cancer has spread to local
lymph glands (nodes). Whether the cancer has spread to other
areas of the body (metastasised). Exactly what tests are needed depends
on the initial assessment and the results
of the biopsy. For example, the biopsy
may show that the cancer is at a very
early stage and remains just in the
surface cells of the cervix. This is unlikely to have spread (metastasised) and you
may not need many other tests.
However, if the cancer appears to be
more advanced and likely to have spread
then a range of tests may be needed. Finding out the stage of the cancer helps
doctors to advise on the best treatment
options. It also gives a reasonable
indication of outlook (prognosis). See
leaflet called 'Cancer Staging and Grading'
for details. What are the treatment options for
cervical cancer? Treatment options which may be
considered include surgery, radiotherapy,
chemotherapy, or a combination of these
treatments. The treatment advised for
each case depends on various factors. For
example, the stage of the cancer (how large the primary cancer tumour is and
whether it has spread), and your general
health. You should have a full discussion with a
specialist who knows your case. They
will be able to give the pros and cons,
likely success rate, possible side-effects,
and other details about the various
possible treatment options for your type and stage of cancer. You should also
discuss with your specialist the aims of
treatment. For example: In some cases, treatment aims to cure the
cancer. Some cervical cancers can be
cured, particularly if they are treated in
the early stages of the disease. (Doctors
tend to use the word 'remission' rather
than the word 'cured'. Remission means there is no evidence of cancer following
treatment. If you are 'in remission', you
may be cured. However, in some cases a
cancer returns months or years later. This
is why doctors are sometimes reluctant
to use the word cured.) In some cases, treatment aims to control
the cancer. If a cure is not realistic, with
treatment it is often possible to limit the
growth or spread of the cancer so that it
progresses less rapidly. This may keep
you free of symptoms for some time. In some cases, treatment aims to ease
symptoms. For example, if a cancer is
advanced then you may require
treatments such as painkillers or other
treatments to help keep you free of pain
or other symptoms. Some treatments may be used to reduce the size of a
cancer which may ease symptoms such
as pain. Surgery An operation to remove the cervix and
uterus (hysterectomy) is a common
treatment. If the cancer is at an early
stage and has not spread then surgery
alone can be curative. In some cases
where the cancer is at a very early stage, it may be possible to just remove the part
of the cervix affected by the cancer
without removing the entire uterus. This
would mean that your fertility would not
be affected. If the cancer has spread to other parts of
the body, surgery may still be advised,
often in addition to other treatments. For
example, in some cases where the cancer
has spread to other nearby structures,
extensive surgery may be an option. This may be to remove not only the cervix and
uterus but also nearby structures which
may have become affected such as the
bladder and/or rectum. Even if the cancer is advanced and a cure
is not possible, some surgical techniques
may still have a place to ease symptoms.
For example, to relieve a blockage of the
bowel or urinary tract which has been
caused by the spread of the cancer. Radiotherapy Radiotherapy is a treatment which uses
high energy beams of radiation which
are focussed on cancerous tissue. This
kills cancer cells, or stops cancer cells
from multiplying. (See leaflet called
'Radiotherapy' for details.) Radiotherapy alone can be curative for early stage
cervical cancer and may be an alternative
to surgery. For more advanced cancers
radiotherapy may be advised in addition
to other treatments. Two types of radiotherapy are used for
cervical cancer, external and internal. In
many cases both types are used. External radiotherapy. This is where
radiation is targeted on the cancer from a
machine. (This is the common type of
radiotherapy used for many types of
cancer.) Internal radiotherapy (brachytherapy).
This treatment involves placing a small
radioactive implant next to the cancerous
tumour for a short time and then it is
removed. (It is put in position via the
vagina.) Even if the cancer is advanced and a cure
is not possible, radiotherapy may still
have a place to ease symptoms. For
example, radiotherapy may be used to
shrink secondary tumours which have
developed in other parts of the body and are causing pain. Chemotherapy Chemotherapy is a treatment using anti-
cancer drugs which kill cancer cells, or
stop them from multiplying. See leaflet
called 'Chemotherapy with Cytotoxic
Drugs' for details. Chemotherapy may be
given in addition to radiotherapy or surgery in certain situations. What is the prognosis (outlook)? The outlook is best in those who are
diagnosed when the cancer is confined to
the cervix and has not spread. Treatment
in this situation gives a good chance of
cure. For women who are diagnosed
when the cancer has already spread, a cure is less likely but still possible. Even if
a cure is not possible, treatment can
often slow down the progression of the
cancer. The treatment of cancer is a developing
area of medicine. New treatments
continue to be developed and the
information on outlook above is very
general. The specialist who knows your
case can give more accurate information about your particular outlook, and how
well your type and stage of cancer is
likely to respond to treatment.