Cervical cancer

Changes in the tissue of the cervix are often harmless, and usually don't cause any problems. It can take years or even decades for cancer to result from these cells. If cancer develops, it can cause the following symptoms:

• Abnormal bleeding – for instance after sex, between periods or after menopause
• Abnormal vaginal discharge that might have an unpleasant odor
• Tiredness and weight loss
• Pain in the abdomen and pelvis
• Pain when urinating (“peeing”)

By the time cervical cancer starts causing symptoms, it is often already at quite an advanced stage.

The cervix is a strong, muscular tube-like structure. The very bottom end of the cervix sticks out into the vagina a little, at the opening of the cervix. The inside of the cervix is lined with a mucous membrane.

Cervical cancer arises from changes in tissue (dysplasias) at the opening of the cervix. These dysplasias are almost always caused by infections with the human papillomaviruses in the skin and mucous membranes. The changes in the tissue often go away on their own. But sometimes particular types of HPV stay in the lining of the cervix for several years or decades. If this happens, the cells may gradually become precancerous and eventually develop into cervical cancer.

The human papillomaviruses are usually spread during sex or by skin-to-skin genital contact. They can also be spread during oral sex if mucous membranes in the mouth touch areas of skin infected with HPV. Human papillomaviruses are not spread by semen, blood or saliva. Many sexually active, non-vaccinated men and women are infected at some point over the course of their lives, often between the ages of 20 and 30. Men can transmit these viruses, and they can also develop various types of cancer from an HPV infection.

Certain women are more likely than others to get cervical cancer. For instance, women who smoke are at higher risk. This might be because their immune systems are less effective at fighting the viruses. Other things that weaken the immune system – such as diseases like AIDS, and medication that is taken after an organ transplant – can increase this risk too.

Because HPV infections are spread through sex, things that generally increase the risk of sexually transmitted infections are also considered to be risk factors for cervical cancer. So, for example, the more sexual partners someone has, the higher their risk of cervical cancer.

Since these regular screening tests were introduced in the 1970s, there has been quite a big drop in the number of women who develop cervical cancer. About 4,600 women develop cervical cancer in Germany each year, and about 1,600 of them die of it. A woman’s risk of cervical cancer mainly depends on whether she goes for screening, whether she has had an HPV vaccine, and how old she is.

The following table shows estimates of how many women of different ages will develop cervical cancer if they don’t go for screening and don’t have an HPV vaccine.

A screening test may show there is reason to believe that a woman has precancerous cell changes or cervical cancer. If you go to your gynecologist for an examination because of abnormal bleeding, discharge or pain, they may find abnormalities.

In this kind of gynecological examination, the doctor feels the area around the womb with their hands, both from the outside (belly) and from the inside (vagina). They also insert a special instrument (speculum) into the vagina, to look at the tissue at the opening of the cervix. If the tissue has changed a lot, it can be examined more closely using a kind of magnifying glass called a colposcope. A sample of tissue can be taken too (biopsy). This is then tested in a lab.

If the lab results confirm that the cervical tissue has abnormal cells or cancer cells in it, what happens next will depend on how much the cells have changed. Smaller areas of abnormal cells and smaller tumors can be removed using surgery called conization. This involves removing a cone-shaped piece of tissue.

If the cancer has already spread to deeper layers of tissue, then more testing is needed to see how advanced it is. Further testing may include ultrasound, x-ray scans, magnetic resonance imaging or computed tomography, and laparoscopy to remove lymph nodes.

Precancerous cell changes that may develop into cervical cancer can be detected in screening tests. These changed tissues can be removed before they have the chance to result in cervical cancer.

A Pap test is carried out. It involves taking a sample of cells from the cervix and examining them in a laboratory. An HPV test is also available: It tests a smear taken from the lining of the cervix for certain human papilloma viruses which are considered to be the main cause of cervical cancer.

In Germany, women between the ages of 20 and 34 can have a free Pap test once a year. Women aged 35 and above are eligible for a combination test of the Pap test and the HPV test every three years. The costs of these tests are covered by German public health insurers.

More testing may be needed depending on the results of the screening tests.

Cervical cancer nearly always develops as a rare consequence of a long-term infection with particular types of HPV. There are four options for prevention:

• HPV vaccine: The German Standing Immunisation Committee (STIKO) in Berlin recommends vaccination between the ages of 9 and 14 years (before first sexual contact is made). Boys and men can also be vaccinated. Then they will not transmit the viruses and are also better protected against certain rare types cancer, such as penile or anal cancer.
• Use condoms: They lower the risk of getting an HPV infection, but are not completely effective. They do not cover all areas of skin in the genital area that could be infected.
• Screening and removal of abnormal tissue before it can develop into cancer
• Sexual contact only with people who have had the HPV vaccine or have not had sex with anyone else, or complete abstinence

The most appropriate type of treatment will mainly depend on the size of the tumor and whether the cancer has spread. If the cervical cancer is discovered at a very early stage, a small surgical procedure (conization) might be enough.

If the tumor has already spread to the surrounding tissue, doctors usually recommend having surgery to remove the entire womb (a hysterectomy). Lymph nodes are also removed.

Radiotherapy might also be considered. It is still an option even if the tumor can no longer be removed through surgery. In some patients it can be combined with chemotherapy. People who have had cancer treatment are generally entitled to rehabilitation therapy (follow-up treatment).

The chances of recovery vary greatly. It is nearly 100% for precancerous tissue and small tumors. About 20% of the women are still alive five years later if the cancer has already spread to nearby organs.

When people need medical advice concerning women's health, they usually go to see their gynecologist first. Information about health care in Germany can help you to navigate the German healthcare system and find a suitable doctor. You can use this list of questions to prepare for your appointment.