Cervical Cancer:
HPV, Vaccination, Screening & Treatment

1. What is cervical cancer?

The cervix is the lower, narrow part of the womb that protrudes into the vagina. Cervical cancer usually develops in the transformation zone of its lining. The most common form is squamous cell carcinoma; less common is adenocarcinoma, which arises from glandular cells and is harder to detect in a smear.^¹

What makes this type of cancer special: it has a clearly known cause and develops via precancerous stages that can be detected and treated over a period of years. That is why cervical cancer has become much less common in countries with good screening. Unlike many other cancers, it affects women in younger and middle adulthood comparatively often.^²

2. HPV: how an infection turns into cancer

Human papillomaviruses are mainly transmitted during sex, including through skin and mucous membrane contact; condoms lower the risk but do not protect completely. The infection is so widespread that most sexually active people become infected at some point in their lives. In the vast majority of cases it clears up unnoticed within one to two years.^³

A distinction is made between low-risk types, which cause genital warts, and high-risk types. Types 16 and 18 are responsible for the majority of cervical cancer cases. High-risk HPV also causes cancer of the vagina, vulva, anus and penis, as well as of the mouth and throat.

1. Infection — usually without consequences, cleared by the immune system.
2. Persistence — in a small proportion of people, the virus remains in the cells for years.
3. Precancerous changes (CIN 1 to 3) — cervical intraepithelial neoplasia is a change in the cells, not yet cancer. Mild changes often regress on their own.
4. Cancer — over many years, an invasive tumour can develop from a high-grade precancerous change.

It is exactly this window of several years that screening makes use of: precancerous changes are found and treated before cancer develops.

3. Symptoms

Precancerous changes and early stages cause no symptoms. That is the most important reason to attend screening even when you feel fine. Possible signs of a more advanced tumour are:^¹

• Bleeding after sex (contact bleeding)
• Bleeding between periods or any bleeding after the menopause
• Changes in vaginal discharge — flesh-coloured, bloody or foul-smelling
• Pain in the lower abdomen or during sex
• Late signs: back or flank pain, swollen legs, problems passing urine or opening your bowels, unintended weight loss

All of these symptoms far more often have harmless causes. But they should be checked promptly by a gynaecologist — especially bleeding after sex or after the menopause.

4. Causes and risk factors

The prerequisite is almost always a persistent high-risk HPV infection. Whether it persists and progresses is influenced by further factors:^¹,³

• Not attending screening — the most important factor you can influence: a large proportion of cases occur in women who have not been screened for a long time.
• Smoking — weakens the defences in the mucous membrane and makes it easier for the infection to persist.
• A weakened immune system — for example with HIV or after an organ transplant.
• Other sexually transmitted infections — for example chlamydia or herpes.
• Many births and becoming sexually active at an early age.

5. Screening and diagnosis

The screening programme

Under the current programme, women with statutory health insurance are entitled to the following examinations:^⁴

• Age 20 to 34: a cytological smear (Pap test) once a year.
• From age 35: a combination of Pap test and HPV test (co-test) every three years.
• Invitations: Health insurers write to women aged between 20 and 65 at regular intervals with information about the programme.
• Even after HPV vaccination: Screening remains important, because the vaccine does not protect against all high-risk types.

If a result is abnormal

An abnormal smear or a positive HPV test does not mean cancer. Usually a repeat check or a diagnostic colposcopy follows: the cervix is examined through a magnifying instrument; after it has been dabbed with diluted acetic acid, altered areas become visible and targeted tissue samples are taken.^³ If cancer is confirmed, a manual examination, an MRI of the pelvis and further imaging establish how far it has spread (FIGO staging).^⁵ Treatment is ideally planned at a tumour board in a certified gynaecological cancer centre. The guide Preparing for a doctor’s appointment helps you get ready for the conversation.

6. Treating precancerous changes

Most abnormal results concern precancerous changes, not cancer. The rule here: do not operate too early, but do not put things off either.^³

An honest assessment: conisation can increase the risk of premature birth in later pregnancies — one reason why surgeons are cautious in young women. After conisation, check-ups with an HPV test and smear follow. Studies suggest that HPV vaccination around the time of conisation may lower the risk of recurrence; whether it makes sense for you and who covers the cost is something to clarify with your practice.

7. Treatment of cervical cancer

Treatment depends mainly on the stage, and also on whether you want to have children, your age and any other conditions. A key principle of the guideline: choose one main treatment wherever possible, because the side effects of surgery and radiotherapy add up.^⁵

Which combination is an option is decided by the treatment team. With a cancer diagnosis, a second opinion is expressly your right, and as a rule it does not significantly delay treatment.

8. Medicines and side effects

During cancer treatment, many medicines often come together: chemotherapy, anti-sickness medicines, cortisone, painkillers, anticoagulants. This makes the medication plan harder to keep track of and interactions more likely.^⁵

• Nausea: Cisplatin is considered strongly nausea-inducing. Combinations are given as a preventive measure, for example with ondansetron and cortisone — according to plan, not only once the nausea has started.
• Kidneys and nerves: Cisplatin can put a strain on the kidneys, hearing and nerves. Drink plenty and report new ringing in the ears or tingling; see polyneuropathy.
• Diarrhoea during radiotherapy: common; take medicines such as loperamide only after checking with your team, because persistent diarrhoea can also point to complications.
• Immunotherapy: Checkpoint inhibitors can trigger inflammation in practically any organ, particularly often in the thyroid (underactive thyroid), the bowel or the skin — even weeks after treatment has ended.
• Herbal remedies: St John’s wort and high-dose supplements can alter the effect of cancer medicines; see herbal medicines.

9. HPV vaccination: who, when, how

HPV vaccination is the most effective single measure against cervical cancer, because it prevents the cause. The Standing Committee on Vaccination (STIKO) at the Robert Koch Institute recommends it for all girls and boys aged 9 to 14. Missed vaccinations should be caught up by the 18th birthday. Depending on age at the start of vaccination, two or three doses are needed.^⁶

• Ideally before first having sex — the vaccine protects against new infections but does not treat an existing one.
• For boys too — it protects against HPV-related cancers of the penis, anus and throat as well as against genital warts, and reduces transmission.
• After the 18th birthday — vaccination can still make sense on an individual basis, but the benefit is usually smaller. Some health insurers cover the cost voluntarily; see vaccinations for adults.
• Well studied — pain at the injection site and headaches are common. Teenagers can faint briefly, which is why the vaccine is given sitting or lying down. There is no evidence that the vaccine causes infertility or autoimmune diseases.

10. Follow-up care and life after treatment

Once treatment is complete, follow-up appointments take place at short intervals in the first years and become less frequent later on. They serve to detect a recurrence early — and just as much to treat late effects.^⁵

• Early menopause — after radiotherapy or removal of the ovaries. Whether hormone replacement therapy is an option depends on the tumour type, among other things; see menopause and hormone replacement therapy.
• Sexuality — vaginal dryness and narrowing of the vagina after radiotherapy are common and treatable, for example with lubricants, local preparations and dilators. Talk about it.
• Lymphoedema — after lymph nodes have been removed, the legs can swell. Early lymphatic drainage and compression help.
• Bladder and bowel — late effects of radiotherapy can appear even years later; new symptoms should be raised at follow-up care.
• Exhaustion and mental health — cancer-related fatigue, fear of recurrence and strain on your relationship are common. Psycho-oncological counselling, rehabilitation and self-help groups are part of care.

Stopping smoking is worthwhile even after the diagnosis. And: cancer treatment increases the risk of thrombosis — a suddenly swollen, painful leg on one side or shortness of breath should be checked immediately; see thrombosis and pulmonary embolism.

Cancer treatment with many medicines — under control with brite

A reminder for every dose, interactions checked, side effects recorded. Free.

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