Tests and results

The cervix

The cervix is the lower part of the uterus, or womb and is sometimes also called the neck of the womb. It is possible for your doctor to see and feel the cervix during an internal (vaginal) examination. The surface layer of the cervix is made up of two different types of cells, flat cells called squamous cells and tall cells called columnar cells. The place where these two cells meet is known as the transformation zone. This area is very important. Abnormal cell changes occur in this area. It is these cells, on the surface of the cervix, which are examined in a cervical smear test.

Who needs a Smear Test?

All women between the ages of 20 and 64 who are or ever have been sexually active should be screened every three years. It may be necessary to have this done more frequently if any abnormalities are noted.

The Smear Test

The idea of a cervical smear is to detect pre-cancerous cells so that they can be removed before they become dangerous. The smear test is a very simple test and only takes a few minutes. It can be slightly uncomfortable. It is not a test for diagnosing cancer. It is a test to check the health of the cervix.
The person taking the smear will explain the procedure and you will be able to ask questions at any time. The current method of taking smears is called the `Pap' smear test. Once you are lying comfortably on the couch the doctor or nurse will gently insert an instrument called a speculum into the vagina to keep the vagina open. The doctor or nurse using a spatula takes a scraping of cells from the cervix (neck of the womb) and "smears" the cells in a thin layer on a glass slide. The doctor or nurse will try to obtain cells from the Transformation Zone as it is here that cancers most often start. The cells are examined by a cytologist in a laboratory who will check for signs of pre-cancerous change.

Smear Result

Most women receive a normal result. Some women receive an abnormal result, which means that the laboratory has found some cell changes which need further investigation. It very rarely means cervical cancer. Abnormal results are often early warning signs - minor changes that can be treated easily. The medical name for these changes is CIN, which stands for cervical intra-epithelial neoplasia. The changes may also be referred to as dyskaryosis.

These abnormal cells are not cancerous but if left untreated they can sometimes go on to develop into cancer of the cervix. CIN can occur to varying degrees. These are called CIN1 , CIN2, and CIN3. These are also called mild, moderate or severe changes.
Mild cell changes and CIN 1
If you have mild cell changes or CIN 1 you may just be asked to have another smear in 3-6 months time. This is because a few slightly abnormal cells can go back to normal by themselves.
Moderate or severe cell changes and CIN 2 or 3
If you have moderate or severe cell changes, or CIN 2 or 3, you will need to have some treatment. You usually only need to be treated once and then have follow up smears. If you do have an abnormal smear and have successful treatment you are very unlikely to get cervical cancer (provided you continue being screened). If you do not have treatment, you are very much at risk from cervical cancer.

Carcinoma in situ

Some cases of CIN 3 can be called 'carcinoma in situ', although this in fact sounds like cancer, it isn't. It means that some of the cells appeared cancerous. But they were all contained within the skin covering the cervix. This is not cancer until the cells break through the top layer of skin covering the cervix into the tissue underneath. If this happens, they can spread to become a true cancer. You must be treated as soon as possible if you have carcinoma in situ. If the affected area is removed, a cancer will have been prevented.

Treatment of CIN

The first step is to have a colposcopy. Colposcopy involves no more than the doctor passing a speculum (in the same way as when you have a smear taken), and then using a modified microscope (colposcope) to look at the cervix. The colposcope does not come into contact with you and the doctor looks into it at the end of the couch. This magnification makes it easier to see all of the transformation zone of the cervix and look for any abnormal areas that might be causing the unusual cells on the smear. If an area looks abnormal, a tiny biopsy (sample) is taken - this is not particularly painful as the biopsy is so small. This allows the pathologist who looked at your smear to see exactly where the abnormal cells were coming from. Knowing this the doctor doing the colposcopy can treat the abnormal area accordingly. Most treatments need no anaesthetic or only local anaesthetic and are carried out in the colposcopy unit. Treatment usually only takes about 20-30 minutes at most, and results in few after-effects. You will be asked to abstain from sex for 10 days or so.
Some units also have a 'see and treat' policy, where biopsy and treatment occur together in one visit .
There are many different ways of treating abnormal cervical cells. You can be treated with

• Laser
• Cold coagulation
• Cryotherapy
• Diathermy

Basically all the treatments aim to do the same thing. The treatment aims to destroy the abnormal cells so that normal cells can grow back in their place.
Or you may be asked to have a:

• LLETZ (large loop excision of the transformation zone)
• Cone biopsy

Hysterectomy

These treatments remove the affected area altogether.

Laser therapy

This treatment is done in a hospital out patients clinic. You will be asked to lie on a couch as you do for a smear test and a speculum will be put into your vagina to hold it open. Your doctor will put local anaesthetic onto your cervix to numb it. Then the laser beam will be used to burn away the abnormal area. You can go home as soon as this treatment is over.

Cold coagulation

This treatment is also done in a hospital out-patients clinic and is similar to laser treatment. It is not treatment with cold as the name suggests. In fact the doctor will use a hot probe to burn away the abnormal cells.

Cryotherapy

This is also an out patient treatment. The doctor uses a cold probe to freeze away the abnormal cells. A speculum will be inserted to keep the vagina open and the cervix visible.

Diathermy

This treatment is done under general anaesthetic. So you will be in hospital for some of the day but will probably go home in the evening. The treatment uses an electric current to destroy the abnormal cells.

LLETZ

Large loop excision of the transformation zone is a treatment that removes the area of abnormal cells completely. It is an out patient treatment. You may be offered this treatment when you have a colposcopy. The transformation zone is cut away using loop of wire. Your doctor should give you a local anaesthetic before treatment starts as it can be uncomfortable.

Cone biopsy

This minor operation can be used to diagnose cervical cancer or treat an abnormal smear. As with LLETZ, the entire area where cells can become abnormal is removed. Cone biopsy is done under general anaesthetic.

Hysterectomy

If you are past your menopause or have had all the children you want to have, your doctor may suggest removing the whole of your womb. This is more likely if you have had abnormal cells found on your cervix more than once or if the abnormality found was severe.

What causes CIN

The exact cause of CIN is still unknown. However, the main cause is infection of the cervix with certain types of human papilloma virus (HPV). HPV (often known as wart virus) is a very common infection. There are many types of the virus and the commonest types can cause warts on the hands or verrucas on the feet. HPV is spread by direct skin-to-skin contact during sex with someone who has the infection. It is more common in women who become sexually active at a young age. HPV is so common that most sexually active women will be exposed to it at some time in their lives. Barrier methods of contraception, such as the cap or condoms, give some, but not total protection against the spread of HPV. In most women their body's own immune system will get rid of the HPV naturally without them ever knowing it was there.

We can now reliably test women for infection with any of the high-risk types of HPV - in other words, the types most closely associated with the development of cervical cancer – by doing a Pap smear or a standard cervical or vaginal swab. If you are found to carry one of the high-risk types of HPV you will need to have additional checks and more frequent Pap smears then would otherwise be required.

The HPV vaccine

A effective vaccine against the HPV has recently been licensed for use in Europe . Called "Gardasil", it provides immunity against HPV types 16 and 18, which together account for approximately 70% of cervical cancers. It also provides immunity against types 6 and 11, which are responsible for most external genital warts. The vaccine will not mean that women will be able to stop having regular Pap smears, but vaccination will reduce a women's lifetime risk of developing cervical cancer.

Current recommendations are that vaccination be offered to young women between the ages of 9 and 26. Older, sexually active women are more likely to have already been exposed to HPV 6, 11, 16 and 18 and the vaccine may not provide additional benefit in this older group of sexually experienced women.