Progression to Cervical Cancer

Persistent HPV infection leads to progression from LSIL (Low-grade Squamous Intraepithelial Lesion) to HSIL (High-grade Squamous Intraepithelial Lesion) and eventually carcinoma.

Risk Factors for Cervical Cancer

• Infection with high-risk HPV

• Early sexual intercourse (before 20 years)

• Having multiple sexual partners or a partner with multiple sexual partners

• Immunosuppression (e.g., HIV infection)

• High parity (3 or more children)

• Local cervical trauma during childbirth

• High rates of cervical abnormalities during pregnancy

• High detection rate of HPV among pregnant women

Additional risk factors include:

• Long-term use of Combined Oral Contraceptives (COCs) – Estrogen acts as an anti-apoptotic agent, promoting the proliferation of HPV-infected cells and increasing vulnerability to mutations.

• Smoking – Smokers have twice the risk compared to non-smokers. Tobacco products are found in cervical mucus and may damage DNA, predisposing to cancer.

• Low socioeconomic status – Associated with limited education, poverty, old age, low access to information, poor health care, and lack of screening.

• Lack of regular screening for cervical cancer.

Signs and Symptoms of Cervical Cancer

Early stages may be asymptomatic.
Common symptoms include:

• Abnormal vaginal bleeding: during or after sexual intercourse, between menstrual periods, or after menopause.

• Abnormal vaginal discharge: foul-smelling, watery, thick, mucoid, bloody, or purulent (pus-like).

• Pain: lower abdominal pain, lower back pain, and pain during sexual intercourse (dyspareunia).

• Abnormal bowel or urinary symptoms: due to pressure on the bladder or rectum or metastasis; may present as constipation, blood in stool, rectal bleeding, hematuria, dysuria, urinary frequency, or obstruction.

On vaginal/speculum examination:

• Abnormal cervix with cervical mass or growth (fungating), ulcer, or easily bleeding on contact.

• The cervix may be fixed, enlarged, or hard.

• Adnexa may be free or fixed with possible vaginal involvement.

• Weight loss—common in advanced stages.

Over 80% of women are diagnosed at a late stage, when cure is no longer achievable. Many cases remain undocumented.

Staging of Cervical Cancer (FIGO Classification)

Stage I: Cancer confined to the cervix

• IA: Microscopic lesions with stromal invasion ≤5 mm deep and ≤7 mm wide

  • IA1: Invasion ≤3 mm in depth

  • IA2: Invasion >3 mm depth

• IB: Macroscopic lesions confined to the cervix

  • IB1: Lesions ≤4 cm in size

  • IB2: Lesions >4 cm in size

Stage II: Cancer extends beyond the cervix but not to pelvic wall or lower third of vagina

• IIA: No parametrial involvement

  • IIA1: Tumor <4 cm, involves upper two-thirds of vagina

  • IIA2: Tumor >4 cm, involves upper two-thirds of vagina

• IIB: Obvious parametrial involvement

Stage III: Tumor extends to pelvic wall and/or lower third of vagina

• IIIA: No extension to pelvic walls but involves lower third of vagina

• IIIB: Extension to pelvic walls or causes hydronephrosis/nonfunctioning kidneys

Stage IV: Tumor extends beyond true pelvis or involves bladder/rectum

• IVA: Growth to adjacent pelvic organs

• IVB: Spread to distant organs (liver, lungs)

Treatment of Cervical Cancer

Prevention of Cervical Cancer

1. Sexual Behavior Change

• Abstinence

• Avoiding early sexual debut

• Avoiding multiple sexual partners

• Consistent condom use

2. Vaccination

• HPV vaccine (Gardasil) — quadrivalent, active against HPV types 6, 11, 16, and 18.

• Administered as two IM injections (0 and 6 months) before sexual debut.

• Target group: girls aged 10–14 years.

3. Cervical Cancer Screening

• Methods:

  • Visual Inspection with Acetic Acid (VIA)

  • Visual Inspection with Lugol’s Iodine (VILI)

  • PAP smear

  • HPV DNA testing

  • Colposcopy and Cervical Biopsy

4. Early Treatment of Premalignant Lesions

• Cryotherapy

• LEEP

• Thermocoagulation