A practical guide to tests and treatments Contents Contents About this booklet 4 Section 1: Cervical screening 6 The cervix 7 Cervical screening 9 The screening test 12 Can cervical screening prevent cancer? 15 Abnormal test results 18 Section 2: Cervical intra-epithelial neoplasia (CIN) 23 What is CIN? 24 Causes of CIN 24 Symptoms of CIN and HPV 26 How CIN is diagnosed 27 Grading of CIN 29 Treating CIN 30 After treatment 38 Follow-up 40 Pregnancy and abnormal cervical screening results 42 Your feelings 44 How we can help you 45 1 Understanding cervical screening Other useful organisations 49 Further resources 52 Your notes and questions 55 2 Understanding cervical screening About this booklet This information is for women who have had, or are about to have, a cervical screening test. We hope that it answers some of the questions you may have. This booklet is divided into two sections. The first section aims to help you understand how cervical screening is done and what further tests may be needed if you have an abnormal test result. The second section is about the causes, diagnosis and treatment of cell changes in the cervix (cervical intra-epithelial neoplasia, CIN). We can’t advise you about the best treatment for yourself. This information can only come from your own doctor, who knows your full medical history. We have a booklet called Understanding cervical cancer, which is for women who have been diagnosed with cancer of the cervix. We can send you a copy. If you’d like to discuss this information, call the Macmillan Support Line free on 0808 808 00 00, Monday–Friday, 9am–8pm. If you’re hard of hearing you can use textphone 0808 808 0121, or Text Relay. For non-English speakers, interpreters are available. Alternatively, visit macmillan.org.uk 4 About this booklet Turn to pages 49–54 for some useful addresses and websites, and pages 55–56 to write down questions for your doctor or nurse. If you find this booklet helpful, you could pass it on to your family and friends. They may also want information to help them support you. 5 Understanding cervical screening Section 1: Cervical screening The cervix 7 Cervical screening 9 The screening test 12 Can cervical screening prevent cancer? 15 Abnormal test results 18 6 The cervix The cervix The cervix is the lower part of the womb (uterus) and is often called the neck of the womb. It’s possible for your doctor or nurse to see and feel the cervix during an internal (vaginal) examination. Fallopian tube Ovary Bladder Womb Cervical Cervix canal Vagina Urethra The cervix and surrounding structures The surface of the outside of the cervix is covered with flat cells called squamous cells. The cervical canal (endocervix) is lined with longer cells called columnar cells or glandular cells, which produce mucus. The area where these cells meet is known as the transformation zone (see page 8). Cells in this transformation zone can become abnormal. It is these cells, on the surface of the cervix, that are examined in a cervical screening test. 7 Understanding cervical screening Womb (uterus) Cervical canal Transformation zone The transformation zone 8 Cervical screening Cervical screening Cervical screening is a way of detecting early changes to cells of the cervix. It’s not a test for cancer, but it can help prevent cervical cancer by identifying early abnormalities that could become cancer if left untreated. The first step in cervical screening is to take a sample of cells from the cervix using a method known as liquid-based cytology (see page 13). This is often referred to as a cervical smear. In the UK, the NHS provides a cervical screening programme for all women who are registered with a GP. The ages when women are invited to attend, and how often screening takes place, varies slightly between the four countries. In England and Northern Ireland: • women are sent their first invitation for routine cervical screening at the age of 25 • women between the ages of 25–49 are invited for cervical screening every three years • women between the ages of 50–64 are invited for screening every five years. In Scotland, cervical screening is offered every three years to women aged 20–60. In Wales, women aged 20–64 are called for a cervical screening test every three years. 9 Understanding cervical screening Once women reach the age of 60–65 (depending on the country they live in), they are no longer invited to have cervical screening unless they’ve had recent cervical changes or haven’t been screened since they were 50. The reason for an upper age limit is because if the cells in the cervix are normal at this time, it’s very unlikely that a cancer will develop in later years. However, women aged 60 and over who’ve never had a screening test are entitled to have one. Women under 25 (20 in Wales and Scotland) aren’t routinely screened as part of the screening programme because changes in a young woman’s cervix are quite normal. In this situation, screening may lead to unnecessary treatment. Research has also shown that screening women in their early 20s isn’t very effective at preventing cervical cancer. Women who have never been sexually active have a very low risk of developing cervical cancer. However, although their risk is very low, there’s still a small possibility of cervical cancer so screening is still recommended. If you’ve never had sex you may choose not to be screened, and your GP or practice nurse can discuss this with you further. Women who are no longer sexually active, but who were in the past, are still recommended to be screened when invited. This also applies to women who’ve been vaccinated against human papilloma virus (HPV) – see page 26. Women who’ve never had penetrative sex and women in same-sex relationships are also advised to be screened as they may still have been exposed to HPV (see pages 24–25). 10 Cervical screening Women of any age, who’ve had treatment for abnormal cells on the cervix within the last 10 years, may need to have a screening test more often than suggested on page 9. Your GP can discuss this with you. Where to go for your screening test You’ll be sent a letter from your local primary care support service or GP asking you to make an appointment for your screening test. Most women choose to have the test done by their practice nurse or GP. You can ask to have it done by a female doctor or nurse if you prefer. Cervical screening tests can also be done at a family planning clinic, Well Woman clinic, sexual health clinic or a genitourinary clinic. NHS Direct (see page 54) can give you details of your local clinic. Screening tests can also be done at private clinics. 11 Understanding cervical screening The screening test Cervical screening isn’t a test for cancer. It’s used to detect early changes in cells of the cervix, which may develop into cancer in the future. Preparing for the test Before you have your cervical screening test, you may find it helpful to consider the following factors: • The best time to have the test is before or after your period, when you are not bleeding. • If you’re pregnant when you are invited for your routine cervical screening test, tell your GP. Your GP will usually recommend that you wait to have your test three months after you have given birth. Occasionally, you may be asked to have a screening test while you’re pregnant (see page 42). Many women feel nervous and embarrassed about going for a cervical screening test. These are natural emotions and they shouldn’t stop you having it done. If you feel unsure about having the test, it may be helpful to discuss your concerns and worries with the practice nurse or your GP. They can talk to you about the screening and reassure you so you feel able to have the test. 12 The screening test Having the test Cervical screening is done using a test called liquid-based cytology. It’s a very simple procedure and takes less than five minutes. It can be uncomfortable but shouldn’t be painful. There are no side effects, and once it’s over you should be able to get back to your normal day. The person carrying out the test will explain the procedure, and you should feel able to ask questions at any time. Once you’re lying comfortably on the couch, the doctor or nurse will gently put an instrument called a speculum into your vagina so that your cervix can be seen. A special brush will be used to gently take cells from the cervix. The head of the brush is then either rinsed into a small container of preservative, or snapped off and put into the container. The container will be sent to the laboratory for examination. In the laboratory, any blood or mucus that could spoil the test is removed from the sample. Then a thin layer of cervical cells are then spread onto a slide and examined under a microscope. ‘In my experience it’s not painful, I’m not particularly embarrassed, and it’s just one of those things that you want to get done to make sure everything is alright.’ Cathy 13 Understanding cervical screening Results You’ll receive a letter with your results within about two weeks of having the test done.