Information For Women

The numbers of cases of cervical cancer has been falling dramatically since the introduction of computerised call and recall for women to regularly have their cervical smears.

Since 1988 there has been a reduction of more than 40% in the registration of new cases and the rate has continued to fall by about 7% per year. This however depends upon all eligible women attending for their smears when invited and in England means that all women aged 25-65 years should have a smear every 3 years until they are 50 then every 5 years thereafter. The frequency of smear taking is slightly different in Northern Ireland, Wales and Scotland.

More cervical cancers are detected at a microscopic stage and can be treated in some cases without major surgery. Surgeons have also improved surgical techniques involving vaginal and laparoscopic (keyhole) procedures. Radiotherapy techniques have also improved.
The cervical screening story in the UK is a success story but there is no room for complacency and the most important message, is to ensure that you attend for your smear is taken when it is due.

Check this link For more information about the cervical screening programme.

Cervical cancer is now uncommon in the UK as a result of the cervical screening programme. The single most important risk factor for developing cervical cancer is infection with human papillomavirus (HPV). This is a tiny virus which infects skin or mucosa. There are over 100 different types of HPV. They infect only humans and different types infect only specific sites e.g genital area or skin

HPV is a very common sexually transmitted infection but it is usually only transient. Many women will have an HPV infection at some time in their lives, usually in their teens or twenties. However, most women clear this infection spontaneously with no long-term effects.

Many HPV types are called ‘low risk’ types and these do not cause cancer. The HPV types commonly linked with cervical and cervical pre-cancer (usually called CIN) are called high risk (or oncogenic). High risk types of human papillomavirus (hrHPV) are detected in almost all cervical cancers and persistent infection with hrHPV is the single most important factor in the development of CIN and of invasive cancer. HPV 16 is the most prevalent type being found in about 70% of cervical cancers and HPV 18 the next most prevalent.

Of those women who have a persistent high risk HPV infection, fewer than 10% would develop cervical disease if this is not detected and treated. Whilst cervical intra-epithelial neoplasia (CIN) is easily treated conservatively, at present there is no specific treatments for HPV infection itself.

A cervical screening (cervical smear) sample is a sample of cells from the outside of the cervix (or neck of the womb) that aims to detect of abnormal pre-cancerous changes of the cervix. These changes can then be treated successfully before cancer develops.

Smear tests are simply screening tools, which identify if more careful attention should be directed at the cervix. Nowadays the sample is first tested for certain strains of the HPV virus and if these are present the laboratory will examine the cells using a technique called cytology.

If your sample does not contain HPV this is known as a negative result and you will be called for another test at the usual or routine time.

If your sample contains HPV but no abnormal cells are detected you will be reminded to have a repeat test in a years time. HPV is very common and the infection will go away by itself in many cases.

If your sample contains HPV and any abnormal cells are detected you will be advised to have a further examination called colposcopy.

In many cases abnormal changes can be reported as abnormal even though no abnormality exists on further examination. In extremely rare cases, smears may detect an abnormality in the presence of a cancer of the cervix.

There are two questions here. HPV or human papilloma virus is an extremely common virus that is acquired through skin to skin contact during sex. Approximately 8 out of 10 adults have had the infection at some time and it is rare for the infection to show any effects at all. However 5% of women will have abnormal smears, 1-2% will develop pre-cancerous cells (CIN) and a tiny minority of these progress to get cervical cancer despite the efforts of the screening programme.

So although HPV is transmitted through sexual activity it is not a sexually transmitted disease or VD that requires a visit to a Sexual Health Clinic. There is no blame to attach to your current or any other partner or to yourself. If you are found to have a HPV infection your cervical screening sample (smear test) will be checked for any abnormal cells. Some abnormal smears with mild changes are due to the effects of HPV on the cervix and may resolve spontaneously as the infection clears.

The one visible abnormality some types of HPV can produce is warts on the vulva or the anus. This is a slightly different situation. These can be treated by the local Sexual Health Clinic. If you have these then your partner would also need examination and possible treatment. Usually a topical cream or freezing of warts is all that is required.

Pre-cancerous changes of the outer (squamous) cells of the cervix are those that have the potential to turn into cancer if left untreated for some time. In the cervix these changes are called ‘Cervical Intraepithelial Neoplasia’ or CIN for short. This rather long term means that the changes are confined to the outermost surface of the cervix and there has been no spread of disease.

There are different grades of CIN according to how severe the changes are, from CIN1 (minor change) to CIN3 (the most severe change). The risk of developing cancer is related to the grade of CIN. We know that most cases of CIN1 will go back to normal without any treatment. The risk of CIN1 developing into cancer is very small. However we know that CIN2 and CIN3 may develop into cancer in some cases, if left untreated. We don’t really know the exact risk of CIN2 and CIN3 turning into cancer as it would be unacceptable to watch this happen without offering treatment merely to see what proportion developed a cancer.

There is a rare abnormality called ‘Cervical Glandular Intraepithelial Neoplasia’ or cGIN and this is the same sort of pre-cancerous change involving the inner glandular cells of the cervix. Treatment of cGIN is usually the same as CIN.

You have just been told that your recent smear was abnormal and you may probably be worried about what is going on and what is likely to happen. You may not even have had a chance to discuss things with your GP or practice nurse and you might even have been sent an appointment directly from the Colposcopy clinic.

The first thing to say is that the vast majority of women in your situation do not have cancer but a condition with changes in the neck of the womb (cervix) that we call CIN. When these changes are found it is normally very easy to get rid of them completely.

Checkout the links on the Information for women page where we hope to give you all the information you need in this section. You may be asked to attend a colposcopy clinic (see what is colposcopy) and an information leaflet may be enclosed with your appointment. You should arrange a convenient appointment time to attend your clinic but still take the opportunity to discuss the findings of the smear with your GP or practice nurse.

Whilst about 1 in 20 women will have a smear test result which is abnormal, only about 1 in 2000 will have cervical cancer. That means approximately 1% of women with any grade of abnormal smear will have a cancer. So statistically speaking the risk that you have already developed cervical cancer is very small even if your smear is abnormal.

We realize though that women worry about this possibility and this is where colposcopy is really helpful. In the majority of women the colposcopy is really reassuring as it shows more clearly what the situation is. So the advice is if you have been referred to colposcopy it is important that you keep your appointment. You will be told there and then whether there is any abnormal area and might even be shown a picture of the problem area(if you like). Many women will not need further treatment but some women will. These treatments are simple and relatively easy and most importantly very effective at getting rid of the problem and returning you to normal tests.

Your smear has been called inadequate. There may be many reasons for this. It is not the fault of the person who took your smear but for one reason or another the process required to produce a sample for the cytologist who reads your smear has been unable to provide a satisfactory specimen. There can be many reasons why; from a simple problem like difficulty in obtaining enough cells for the laboratory to read or too much blood on the smear or a more complex difficulty in the preparation process.

Sometimes your doctor or practice nurse can advise a treatment that may make taking a further sample more effective, such as vaginal oestrogen cream if the inadequate smear is due to postmenopausal changes in the cervix or antibiotics if infection is present.

Importantly an inadequate smear does not mean your smear was abnormal but that it was unreadable. This is an inconvenience but should not make you worry. Ask your doctor or practice nurse why your smear was inadequate and be aware that you will be called for a repeat cervical cytology sample in three months. Waiting for this time before repeating the test, reduces the risk of a further inadequate sample.

The newer smear taking technique called liquid based cytology has made this problem less likely but occasionally women may be referred to colposcopy clinic if the problem persists.

No. There is no evidence that daughters and other female relatives of women with abnormal smears, pre-cancerous cells (CIN) or cervical cancer have an increased risk of abnormal smears, pre-cancerous cells or cervical cancer. Cervical smear abnormalities are common and it is not unusual for one or more family members to have had an abnormal smear, but there is no inherited predisposition to cervical abnormalities, CIN or cervical cancer.

Cervical cancer is now uncommon in the UK as a result of the cervical screening programme. The single most important risk factor for developing cervical cancer is infection with human papillomavirus (HPV). This is a tiny virus which infects skin or mucosa. There are over 100 different types of HPV. They infect only humans and different types infect only specific sites e.g genital area or skin

HPV is a very common sexually transmitted infection but it is usually only transient. Many women will have an HPV infection at some time in their lives, usually in their teens or twenties. However, most women clear this infection spontaneously with no long-term effects.

Many HPV types are called ‘low risk’ types and these do not cause cancer. The HPV types commonly linked with cervical and cervical pre-cancer (usually called CIN) are called high risk (or oncogenic). High risk types of human papillomavirus (hrHPV) are detected in almost all cervical cancers and persistent infection with hrHPV is the single most important factor in the development of CIN and of invasive cancer. HPV 16 is the most prevalent type being found in about 70% of cervical cancers and HPV 18 the next most prevalent.

Of those women who have a persistent high risk HPV infection, fewer than 10% would develop cervical disease if this is not detected and treated. Whilst cervical intra-epithelial neoplasia (CIN) is easily treated conservatively, at present there is no specific treatments for HPV infection itself.

There are two questions here. HPV or human papilloma virus is an extremely common virus that is acquired through skin to skin contact during sex. Approximately 8 out of 10 adults have had the infection at some time and it is rare for the infection to show any effects at all. However 5% of women will have abnormal smears, 1-2% will develop pre-cancerous cells (CIN) and a tiny minority of these progress to get cervical cancer despite the efforts of the screening programme.

So although HPV is transmitted through sexual activity it is not a sexually transmitted disease or VD that requires a visit to a Sexual Health Clinic. There is no blame to attach to your current or any other partner or to yourself. If you are found to have a HPV infection your cervical screening sample (smear test) will be checked for any abnormal cells. Some abnormal smears with mild changes are due to the effects of HPV on the cervix and may resolve spontaneously as the infection clears.

The one visible abnormality some types of HPV can produce is warts on the vulva or the anus. This is a slightly different situation. These can be treated by the local Sexual Health Clinic. If you have these then your partner would also need examination and possible treatment. Usually a topical cream or freezing of warts is all that is required.

Pre-cancerous changes of the outer (squamous) cells of the cervix are those that have the potential to turn into cancer if left untreated for some time. In the cervix these changes are called ‘Cervical Intraepithelial Neoplasia’ or CIN for short. This rather long term means that the changes are confined to the outermost surface of the cervix and there has been no spread of disease.

There are different grades of CIN according to how severe the changes are, from CIN1 (minor change) to CIN3 (the most severe change). The risk of developing cancer is related to the grade of CIN. We know that most cases of CIN1 will go back to normal without any treatment. The risk of CIN1 developing into cancer is very small. However we know that CIN2 and CIN3 may develop into cancer in some cases, if left untreated. We don’t really know the exact risk of CIN2 and CIN3 turning into cancer as it would be unacceptable to watch this happen without offering treatment merely to see what proportion developed a cancer.

There is a rare abnormality called ‘Cervical Glandular Intraepithelial Neoplasia’ or cGIN and this is the same sort of pre-cancerous change involving the inner glandular cells of the cervix. Treatment of cGIN is usually the same as CIN.

You have just been told that your recent smear was abnormal and you may probably be worried about what is going on and what is likely to happen. You may not even have had a chance to discuss things with your GP or practice nurse and you might even have been sent an appointment directly from the Colposcopy clinic.

The first thing to say is that the vast majority of women in your situation do not have cancer but a condition with changes in the neck of the womb (cervix) that we call CIN. When these changes are found it is normally very easy to get rid of them completely.

Checkout the links on the Information for women page where we hope to give you all the information you need in this section. You may be asked to attend a colposcopy clinic (see what is colposcopy) and an information leaflet may be enclosed with your appointment. You should arrange a convenient appointment time to attend your clinic but still take the opportunity to discuss the findings of the smear with your GP or practice nurse.

No. There is no evidence that daughters and other female relatives of women with abnormal smears, pre-cancerous cells (CIN) or cervical cancer have an increased risk of abnormal smears, pre-cancerous cells or cervical cancer. Cervical smear abnormalities are common and it is not unusual for one or more family members to have had an abnormal smear, but there is no inherited predisposition to cervical abnormalities, CIN or cervical cancer.

You have just been told that your recent smear was abnormal and you may probably be worried about what is going on and what is likely to happen. You may not even have had a chance to discuss things with your GP or practice nurse and you might even have been sent an appointment directly from the Colposcopy clinic.

The first thing to say is that the vast majority of women in your situation do not have cancer but a condition with changes in the neck of the womb (cervix) that we call CIN. When these changes are found it is normally very easy to get rid of them completely.

Checkout the links on the Information for women page where we hope to give you all the information you need in this section. You may be asked to attend a colposcopy clinic (see what is colposcopy) and an information leaflet may be enclosed with your appointment. You should arrange a convenient appointment time to attend your clinic but still take the opportunity to discuss the findings of the smear with your GP or practice nurse.

Whilst about 1 in 20 women will have a smear test result which is abnormal, only about 1 in 2000 will have cervical cancer. That means approximately 1% of women with any grade of abnormal smear will have a cancer. So statistically speaking the risk that you have already developed cervical cancer is very small even if your smear is abnormal.

We realize though that women worry about this possibility and this is where colposcopy is really helpful. In the majority of women the colposcopy is really reassuring as it shows more clearly what the situation is. So the advice is if you have been referred to colposcopy it is important that you keep your appointment. You will be told there and then whether there is any abnormal area and might even be shown a picture of the problem area(if you like). Many women will not need further treatment but some women will. These treatments are simple and relatively easy and most importantly very effective at getting rid of the problem and returning you to normal tests.

Your smear has been called inadequate. There may be many reasons for this. It is not the fault of the person who took your smear but for one reason or another the process required to produce a sample for the cytologist who reads your smear has been unable to provide a satisfactory specimen. There can be many reasons why; from a simple problem like difficulty in obtaining enough cells for the laboratory to read or too much blood on the smear or a more complex difficulty in the preparation process.

Sometimes your doctor or practice nurse can advise a treatment that may make taking a further sample more effective, such as vaginal oestrogen cream if the inadequate smear is due to postmenopausal changes in the cervix or antibiotics if infection is present.

Importantly an inadequate smear does not mean your smear was abnormal but that it was unreadable. This is an inconvenience but should not make you worry. Ask your doctor or practice nurse why your smear was inadequate and be aware that you will be called for a repeat cervical cytology sample in three months. Waiting for this time before repeating the test, reduces the risk of a further inadequate sample.

The newer smear taking technique called liquid based cytology has made this problem less likely but occasionally women may be referred to colposcopy clinic if the problem persists.

Colposcopy involves a more detailed examination of the cervix with a bright light and a special magnifying binoculars to see the changes at high magnification. Don’t worry about the sound of this! The magnifying binoculars stay outside you. All that goes inside is the speculum, which is the instrument your GP or practice nurse used to see your cervix when taking your cervical sample.

Many clinics may be equipped with camera equipment so that you can watch the examination if you wish. Some clinics take a picture for your records and you will be asked beforehand if you are agreeable to this being done. The pictures are helpful for comparison, if you have to return for a repeat examination.

The examination takes a little longer than a standard smear test, but the doctor or nurse performing the colposcopy will talk to you, before and during the examination and tell you what is being done.

Checkout this link for more information about colposcopy

You should have the chance to discuss your smear abnormality with your GP or practice nurse. If an appointment is needed at the colposcopy clinic, then this will be sent to you or your GP will send to letter to the clinic. In some places, however, you may receive an appointment directly from the Colposcopy clinic, as they will have been informed of your abnormal smear result, directly by the laboratory.

You should then confirm the appointment with the clinic at a convenient time for you. Whatever the kind of smear abnormality you have, if you are referred for colposcopy you should not have to wait long for the appointment. The vast majority of women referred for colposcopy should be seen within 8 weeks.

Most colposcopists use a combination of the acetic acid and Schiller’s iodine tests. If there is an abnormality the colposcopist should be able to estimate whether it is a likely pre-cancerous abnormality or not according to: 


• How white the tissue goes after using acetic acid
• How quickly the tissue turns white
• How smooth or irregular the surface is
• The different patterns of the blood vessels (mosaic and punctation) under the surface of the cervix

First of all you will be seen by friendly staff who are dedicated to this clinic. They will understand how you may be worried and will take time to discuss your cervical sample (smear) result before the examination. You will be examined on a purpose-built couch. The cervix is viewed using a speculum (the instrument needed for your smear to be taken) and then examined with the colposcope at low magnification (4-10 times magnification). The doctor or nurse will put a number of different solutions on the cervix and look for changes that indicate the presence or otherwise of pre-cancerous changes (or CIN).

Acetic acid colposcopy


Acetic acid (dilute vinegar) is applied to the cervix using a cotton wool ball or by a spray. Abnormal areas such as CIN will tend to turn white (acetowhite). The exact reason why CIN tissue turns white with acetic acid is not fully understood. Also it is important to say that some areas of acetowhite do not indicate CIN at all. One of the challenges facing the colposcopist is to decide which areas of acetowhite truly represent pre-malignancy and to avoid treating minor conditions.

Schiller's iodine test


The colposcopist may use another test using an iodine solution. Normal tissue on the outside of the cervix stains dark brown when iodine is applied. On the other hand, pre-cancerous abnormalities may not stain with iodine. The cells on the inner part of the cervix also do not stain brown. This test may be used following acetic acid colposcopy and is often used before treatment.

To be sure of the diagnosis, a biopsy is often required – this means taking a small sample of tissue from the cervix with a special instrument. This sample is taken very quickly and usually does not require local anaesthetic. Depending on the results of this biopsy the colposcopist will decide whether you need treatment.

In some cases, if it is obvious that you will be likely to need treatment, this can be done at the first visit – in this case all of the abnormal area is removed, and you will be given a local anaesthetic first and this constitutes the biopsy.

These possibilities will be mentioned to you in your information leaflet before your clinic appointment and will be discussed with you in clinic. Your colposcopy should never be painful and if you happen to be having difficulty you should discuss this with the colposcopist. If necessary the colposcopy can be stopped.

Sometimes taking the biopsy can be uncomfortable, but the person performing the colposcopy will warn you before the biopsy is to be taken. You may have a blood stained discharge or light bleeding for a few days. During this time you should avoid sexual intercourse and tampons.

Pre-cancerous changes of the outer (squamous) cells of the cervix are those that have the potential to turn into cancer if left untreated for some time. In the cervix these changes are called ‘Cervical Intraepithelial Neoplasia’ or CIN for short. This rather long term means that the changes are confined to the outermost surface of the cervix and there has been no spread of disease.

There are different grades of CIN according to how severe the changes are, from CIN1 (minor change) to CIN3 (the most severe change). The risk of developing cancer is related to the grade of CIN. We know that most cases of CIN1 will go back to normal without any treatment. The risk of CIN1 developing into cancer is very small. However we know that CIN2 and CIN3 may develop into cancer in some cases, if left untreated. We don’t really know the exact risk of CIN2 and CIN3 turning into cancer as it would be unacceptable to watch this happen without offering treatment merely to see what proportion developed a cancer.

There is a rare abnormality called ‘Cervical Glandular Intraepithelial Neoplasia’ or cGIN and this is the same sort of pre-cancerous change involving the inner glandular cells of the cervix. Treatment of cGIN is usually the same as CIN.

You may have heard that CIN and cervical cancer is caused by a viral infection with human papillomavirus (HPV). These are in fact a large family of viruses, only a few of which are involved in causing abnormalities of the cervix and lower genital tract. Of the over 150 HPV viruses, the main types responsible for changes to the cervix are types 16,18,31,33 and 45. While it is true that virtually all women with CIN and cervical cancer have had HPV infection, so have a huge number of other people without disease. About 4 out of 5 adult men and women have had HPV infection at some time in their lives, but only a small minority of women with an HPV infection ultimately have an abnormal smear and a tiny fraction of these get cervical cancer.

It is acquired or caught in almost all cases through close intimate or sexual contact, but the infection is so common and so subtle that referral to a sexually transmitted disease clinic is not appropriate. It should also not be considered a ‘VD’ or venereal disease. Certainly no antibiotics or other treatment for HPV infection is required.

HPV only causes cervical smear abnormalities if it is not cleared from the body over a period of years. The smear abnormality requires further examination and sampling and sometimes treatment in colposcopy clinic. Within the next year, a test for HPV infection when borderline and mild smear abnormalities are reported will be part of routine practice in England.

Immunisation against HPV started in September 2008 for girls aged 12 to 13 with a catch up for girls up to 18 in the following 3 years. It is however, unlikely to alter the rates of smear abnormalities for many years.

You should be aware that smoking can make clearing HPV from the body less effective and can make clearance of minor smear abnormalities slower and less efficient. For this reason stopping smoking may be advised by your GP, practice nurse or staff in the colposcopy clinic.

There are a number of different ways that pre cancerous changes or CIN can be treated. The treatment options available are either to remove a small part of the cervix or neck of the womb (called excision) or to treat by heating the tissue (called ablation).

Treatments which include excision

Cervical cone biopsy has been used since the 1960s. A laser can be used to cut the cone as an alternative to a surgeon’s knife.

You may have heard of ‘loop treatment’ as this is the commonest way of treating CIN today. The full name for the procedure is ‘Large Loop Excision of the Transformation Zone’ or LLETZ for short. The abnormal area is removed using a wire loop through which an electric current is passed. This can usually be performed after you are given local anaesthetic to ‘numb’ the cervix. LLETZ is a simple and safe technique which gives excellent results. Treatment can be offered at the first visit and if your clinic offers this service then you will be advised in advance in the documentation about your clinic appointment.

Treatments which include ablation

These treatments do not involve the removal of tissue from your cervix but destroy the abnormal changes in situ. If ablation is chosen for your method of treatment a small biopsy is required at the first visit and when the result of the biopsy is available, you will be offered a further appointment to return and then have your treatment. The commonest of these treatments is called thermal ablation or cold coagulation but some clinics have access to a laser for this.

Which treatment?

The reason for choosing one treatment instead of another depends on whether this is your first treatment, the site or size of any abnormality or the exact microscopic appearance of the pre-cancerous abnormality (CIN 1, 2 or 3, cGIN). Not all situations are suitable for ablative treatments. If selected carefully, all treatment methods are highly effective.

If your treatment was carried out with a local anaesthetic, you may notice some period-like cramps as the anaesthetic wears off. If this is the case, try taking 2 x 500mg paracetamol or 2 x 200mg Ibuprofen (if you have no allergies or previous problems with Aspirin) tablets to relieve the pain.

If the CIN has been treated by LLETZ (loop treatment) you will have a blood-stained vaginal discharge for some time. This usually settles in 2 weeks but may last for up to 4-6 weeks. The discharge should not be heavier than a period and should get progressively lighter. If you are worried that this is not the case, you should have been given the contact number of a person you can call at the clinic. Otherwise you should contact your GP.

You should be given an information leaflet informing you what to expect after treatment and advising you of telephone numbers to contact if you have any problems.

You are usually to avoid sexual intercourse for 4 weeks after treatment. You should also avoid using tampons during this time. You may be advised to avoid bathing or swimming for 2-4 weeks.

There is no evidence that the flow during your period is increased or that the regularity of your cycle is altered by treatment. Rarely periods may disappear particularly after a cone biopsy (this is the treatment that is usually performed with a general anaesthetic) but this is due to a rare complication called cervical stenosis, where the cervix becomes blocked and cramp like period pains, continue because of blood becoming trapped in the uterus (or womb). This can usually be dealt with by a procedure to open the cervix and release the trapped blood.

Any treatment involves a balance between getting rid of any abnormal cells on the one hand and minimising any possible harm on the other hand.

Clearly the more of your cervix which has been removed the less supporting tissue is available for future pregnancies. Your colposcopist will recognise the importance of the cervix to support future pregnancies and will tend to remove as little tissue as possible while making sure the treatment is successful.Women having had treatment for abnormal cells by loop excision may have a higher risk of preterm delivery in later pregnancies. Other treatments such as laser ablation or cold coagulation have not been associated with this adverse finding but these treatments may not be suitable for your problem.

A type of treatment called cone biopsy (this usually requires admission to hospital and is performed whilst you are asleep with a general anaesthetic) or repeated treatments may also result in early delivery. If you have had multiple treatments and are pregnant or considering a pregnancy then you should speak to your GP or obstetrician.

While there currently appears to be no ideal way to judge this risk, there are ways that it can be managed. You should discuss your previous treatment with your obstetrician who sometimes may advise a special scan early in pregnancy to measure the length of your cervix. In most cases this is normal, but if not your doctor may recommend a cervical stitch (or cerclage) to provide additional support. This is generally inserted when you are pregnant with a short general anaesthetic and removed whilst you are awake shortly before your baby is due.

If you have a coil (or IUCD/ Mirena IUS) then this need not be removed, if you are expecting treatment in colposcopy clinic. Most colposcopists will perform a colposcopy and if a loop excision form of treatment is needed, then consider performing the loop ‘around’ the coil and coil threads. Sometimes the threads are inadvertently cut but this is not a problem as a coil can be removed (when you no longer wish to use it) without the threads.

If you have had treatment to the cervix after having had an abnormal smear, it is important to have a smear check about 6 months later. This is to see that the treatment has been effective. This is usually at your Colposcopy clinic, but sometimes this can be back with your GP or practice nurse. A lot of clinics also invite you for a follow-up colposcopy examination at this stage and will take the smear as well.

From 2012 you may in addition have a special test to check that any infection with the human papillomavirus (HPV) has resolved. If all is normal at this stage you will simply have annual smears for a number of years (depending on your specific circumstances) before going back on the normal 3 or 5 yearly smears. If any further abnormalities are detected on your tests you will be invited to have a further colposcopy examination.

A hysterectomy is very rarely used as a specific treatment for women with abnormal smears. It may be recommended after 2 or 3 local treatments have failed to remove a pre-cancerous problem, or if for technical reasons further smears cannot be taken from a cervix having had multiple treatments. Other women suitable for hysterectomy may have other difficulties such as heavy periods and abnormal cells making a hysterectomy a practical common solution. A hysterectomy may be recommended for an early cervical cancer or a glandular abnormality.

In all cases detailed discussion with your gynaecologist is required to decide whether you can have the hysterectomy as a vaginal, abdominal or laparoscopic (or keyhole) procedure and whether you should keep your ovaries or have them removed.

It is important to remember that while hysterectomy usually removes the cervix you will still need to have follow up smear tests as in unusual cases abnormal cells can recur in the vagina.

The combined oral contraceptive pill is associated with a very slightly increased risk of cervical cancer. A recent series of publications found this to be in women that have HPV. This is not very helpful, as HPV almost always has no symptoms (except rarely causing genital warts due to some types of HPV) and most adults at some stage of their lives do have HPV, although in most cases the infection is short lasting (a matter of months). Family planning doctors strongly recommend that women requiring contraception should use a reliable method. The combined pill is a good method of contraception. If you have an abnormal smear and are taking the combined pill, you should continue to take the pill. It has no effect on making any changes occur any faster.

You should have the chance to discuss your smear abnormality with your GP or practice nurse. If an appointment is needed at the colposcopy clinic, then this will be sent to you or your GP will send to letter to the clinic. In some places, however, you may receive an appointment directly from the Colposcopy clinic, as they will have been informed of your abnormal smear result, directly by the laboratory.

You should then confirm the appointment with the clinic at a convenient time for you. Whatever the kind of smear abnormality you have, if you are referred for colposcopy you should not have to wait long for the appointment. The vast majority of women referred for colposcopy should be seen within 8 weeks.

First of all you will be seen by friendly staff who are dedicated to this clinic. They will understand how you may be worried and will take time to discuss your cervical sample (smear) result before the examination. You will be examined on a purpose-built couch. The cervix is viewed using a speculum (the instrument needed for your smear to be taken) and then examined with the colposcope at low magnification (4-10 times magnification). The doctor or nurse will put a number of different solutions on the cervix and look for changes that indicate the presence or otherwise of pre-cancerous changes (or CIN).

Acetic acid colposcopy


Acetic acid (dilute vinegar) is applied to the cervix using a cotton wool ball or by a spray. Abnormal areas such as CIN will tend to turn white (acetowhite). The exact reason why CIN tissue turns white with acetic acid is not fully understood. Also it is important to say that some areas of acetowhite do not indicate CIN at all. One of the challenges facing the colposcopist is to decide which areas of acetowhite truly represent pre-malignancy and to avoid treating minor conditions.

Schiller's iodine test


The colposcopist may use another test using an iodine solution. Normal tissue on the outside of the cervix stains dark brown when iodine is applied. On the other hand, pre-cancerous abnormalities may not stain with iodine. The cells on the inner part of the cervix also do not stain brown. This test may be used following acetic acid colposcopy and is often used before treatment.

Most colposcopists use a combination of the acetic acid and Schiller’s iodine tests. If there is an abnormality the colposcopist should be able to estimate whether it is a likely pre-cancerous abnormality or not according to: 


• How white the tissue goes after using acetic acid
• How quickly the tissue turns white
• How smooth or irregular the surface is
• The different patterns of the blood vessels (mosaic and punctation) under the surface of the cervix

To be sure of the diagnosis, a biopsy is often required – this means taking a small sample of tissue from the cervix with a special instrument. This sample is taken very quickly and usually does not require local anaesthetic. Depending on the results of this biopsy the colposcopist will decide whether you need treatment.

In some cases, if it is obvious that you will be likely to need treatment, this can be done at the first visit – in this case all of the abnormal area is removed, and you will be given a local anaesthetic first and this constitutes the biopsy.

These possibilities will be mentioned to you in your information leaflet before your clinic appointment and will be discussed with you in clinic. Your colposcopy should never be painful and if you happen to be having difficulty you should discuss this with the colposcopist. If necessary the colposcopy can be stopped.

Sometimes taking the biopsy can be uncomfortable, but the person performing the colposcopy will warn you before the biopsy is to be taken. You may have a blood stained discharge or light bleeding for a few days. During this time you should avoid sexual intercourse and tampons.

Pre-cancerous changes of the outer (squamous) cells of the cervix are those that have the potential to turn into cancer if left untreated for some time. In the cervix these changes are called ‘Cervical Intraepithelial Neoplasia’ or CIN for short. This rather long term means that the changes are confined to the outermost surface of the cervix and there has been no spread of disease.

There are different grades of CIN according to how severe the changes are, from CIN1 (minor change) to CIN3 (the most severe change). The risk of developing cancer is related to the grade of CIN. We know that most cases of CIN1 will go back to normal without any treatment. The risk of CIN1 developing into cancer is very small. However we know that CIN2 and CIN3 may develop into cancer in some cases, if left untreated. We don’t really know the exact risk of CIN2 and CIN3 turning into cancer as it would be unacceptable to watch this happen without offering treatment merely to see what proportion developed a cancer.

There is a rare abnormality called ‘Cervical Glandular Intraepithelial Neoplasia’ or cGIN and this is the same sort of pre-cancerous change involving the inner glandular cells of the cervix. Treatment of cGIN is usually the same as CIN.

You may have heard that CIN and cervical cancer is caused by a viral infection with human papillomavirus (HPV). These are in fact a large family of viruses, only a few of which are involved in causing abnormalities of the cervix and lower genital tract. Of the over 150 HPV viruses, the main types responsible for changes to the cervix are types 16,18,31,33 and 45. While it is true that virtually all women with CIN and cervical cancer have had HPV infection, so have a huge number of other people without disease. About 4 out of 5 adult men and women have had HPV infection at some time in their lives, but only a small minority of women with an HPV infection ultimately have an abnormal smear and a tiny fraction of these get cervical cancer.

It is acquired or caught in almost all cases through close intimate or sexual contact, but the infection is so common and so subtle that referral to a sexually transmitted disease clinic is not appropriate. It should also not be considered a ‘VD’ or venereal disease. Certainly no antibiotics or other treatment for HPV infection is required.

HPV only causes cervical smear abnormalities if it is not cleared from the body over a period of years. The smear abnormality requires further examination and sampling and sometimes treatment in colposcopy clinic. Within the next year, a test for HPV infection when borderline and mild smear abnormalities are reported will be part of routine practice in England.

Immunisation against HPV started in September 2008 for girls aged 12 to 13 with a catch up for girls up to 18 in the following 3 years. It is however, unlikely to alter the rates of smear abnormalities for many years.

You should be aware that smoking can make clearing HPV from the body less effective and can make clearance of minor smear abnormalities slower and less efficient. For this reason stopping smoking may be advised by your GP, practice nurse or staff in the colposcopy clinic.

The combined oral contraceptive pill is associated with a very slightly increased risk of cervical cancer. A recent series of publications found this to be in women that have HPV. This is not very helpful, as HPV almost always has no symptoms (except rarely causing genital warts due to some types of HPV) and most adults at some stage of their lives do have HPV, although in most cases the infection is short lasting (a matter of months). Family planning doctors strongly recommend that women requiring contraception should use a reliable method. The combined pill is a good method of contraception. If you have an abnormal smear and are taking the combined pill, you should continue to take the pill. It has no effect on making any changes occur any faster.

There are a number of different ways that pre cancerous changes or CIN can be treated. The treatment options available are either to remove a small part of the cervix or neck of the womb (called excision) or to treat by heating the tissue (called ablation).

Treatments which include excision

Cervical cone biopsy has been used since the 1960s. A laser can be used to cut the cone as an alternative to a surgeon’s knife.

You may have heard of ‘loop treatment’ as this is the commonest way of treating CIN today. The full name for the procedure is ‘Large Loop Excision of the Transformation Zone’ or LLETZ for short. The abnormal area is removed using a wire loop through which an electric current is passed. This can usually be performed after you are given local anaesthetic to ‘numb’ the cervix. LLETZ is a simple and safe technique which gives excellent results. Treatment can be offered at the first visit and if your clinic offers this service then you will be advised in advance in the documentation about your clinic appointment.

Treatments which include ablation

These treatments do not involve the removal of tissue from your cervix but destroy the abnormal changes in situ. If ablation is chosen for your method of treatment a small biopsy is required at the first visit and when the result of the biopsy is available, you will be offered a further appointment to return and then have your treatment. The commonest of these treatments is called thermal ablation or cold coagulation but some clinics have access to a laser for this.

Which treatment?

The reason for choosing one treatment instead of another depends on whether this is your first treatment, the site or size of any abnormality or the exact microscopic appearance of the pre-cancerous abnormality (CIN 1, 2 or 3, cGIN). Not all situations are suitable for ablative treatments. If selected carefully, all treatment methods are highly effective.

If your treatment was carried out with a local anaesthetic, you may notice some period-like cramps as the anaesthetic wears off. If this is the case, try taking 2 x 500mg paracetamol or 2 x 200mg Ibuprofen (if you have no allergies or previous problems with Aspirin) tablets to relieve the pain.

If the CIN has been treated by LLETZ (loop treatment) you will have a blood-stained vaginal discharge for some time. This usually settles in 2 weeks but may last for up to 4-6 weeks. The discharge should not be heavier than a period and should get progressively lighter. If you are worried that this is not the case, you should have been given the contact number of a person you can call at the clinic. Otherwise you should contact your GP.

You should be given an information leaflet informing you what to expect after treatment and advising you of telephone numbers to contact if you have any problems.

You are usually to avoid sexual intercourse for 4 weeks after treatment. You should also avoid using tampons during this time. You may be advised to avoid bathing or swimming for 2-4 weeks.

There is no evidence that the flow during your period is increased or that the regularity of your cycle is altered by treatment. Rarely periods may disappear particularly after a cone biopsy (this is the treatment that is usually performed with a general anaesthetic) but this is due to a rare complication called cervical stenosis, where the cervix becomes blocked and cramp like period pains, continue because of blood becoming trapped in the uterus (or womb). This can usually be dealt with by a procedure to open the cervix and release the trapped blood.

Any treatment involves a balance between getting rid of any abnormal cells on the one hand and minimising any possible harm on the other hand.

Clearly the more of your cervix which has been removed the less supporting tissue is available for future pregnancies. Your colposcopist will recognise the importance of the cervix to support future pregnancies and will tend to remove as little tissue as possible while making sure the treatment is successful.Women having had treatment for abnormal cells by loop excision may have a higher risk of preterm delivery in later pregnancies. Other treatments such as laser ablation or cold coagulation have not been associated with this adverse finding but these treatments may not be suitable for your problem.

A type of treatment called cone biopsy (this usually requires admission to hospital and is performed whilst you are asleep with a general anaesthetic) or repeated treatments may also result in early delivery. If you have had multiple treatments and are pregnant or considering a pregnancy then you should speak to your GP or obstetrician.

While there currently appears to be no ideal way to judge this risk, there are ways that it can be managed. You should discuss your previous treatment with your obstetrician who sometimes may advise a special scan early in pregnancy to measure the length of your cervix. In most cases this is normal, but if not your doctor may recommend a cervical stitch (or cerclage) to provide additional support. This is generally inserted when you are pregnant with a short general anaesthetic and removed whilst you are awake shortly before your baby is due.

If you have a coil (or IUCD/ Mirena IUS) then this need not be removed, if you are expecting treatment in colposcopy clinic. Most colposcopists will perform a colposcopy and if a loop excision form of treatment is needed, then consider performing the loop ‘around’ the coil and coil threads. Sometimes the threads are inadvertently cut but this is not a problem as a coil can be removed (when you no longer wish to use it) without the threads.

A hysterectomy is very rarely used as a specific treatment for women with abnormal smears. It may be recommended after 2 or 3 local treatments have failed to remove a pre-cancerous problem, or if for technical reasons further smears cannot be taken from a cervix having had multiple treatments. Other women suitable for hysterectomy may have other difficulties such as heavy periods and abnormal cells making a hysterectomy a practical common solution. A hysterectomy may be recommended for an early cervical cancer or a glandular abnormality.

In all cases detailed discussion with your gynaecologist is required to decide whether you can have the hysterectomy as a vaginal, abdominal or laparoscopic (or keyhole) procedure and whether you should keep your ovaries or have them removed.

It is important to remember that while hysterectomy usually removes the cervix you will still need to have follow up smear tests as in unusual cases abnormal cells can recur in the vagina.

If you have had treatment to the cervix after having had an abnormal smear, it is important to have a smear check about 6 months later. This is to see that the treatment has been effective. This is usually at your Colposcopy clinic, but sometimes this can be back with your GP or practice nurse. A lot of clinics also invite you for a follow-up colposcopy examination at this stage and will take the smear as well.

From 2012 you may in addition have a special test to check that any infection with the human papillomavirus (HPV) has resolved. If all is normal at this stage you will simply have annual smears for a number of years (depending on your specific circumstances) before going back on the normal 3 or 5 yearly smears. If any further abnormalities are detected on your tests you will be invited to have a further colposcopy examination.

Sometimes a smear result will come back as atypical glandular cells and the following is an explanation of this.

There are two groups of cells on the cervix – outer cells which are called ectocervical or squamous cells and inner cells also called glandular/ columnar or endocervical cells. Abnormalities can occur in both groups of cells but are much commoner in the outer or squamous cells (called dyskaryosis on smear and CIN on a tissue biopsy).

In the event of having an abnormality in the glandular cells on a smear test (called Atypical Glandular cells on smear), you will be referred either directly by the Laboratory or your smear taker to the Colposcopy clinic.

The colposcopist will perform a colposcopic examination and may or may not perform a biopsy at the time. They may also suggest an ultrasound scan of the pelvis to look at the uterus (womb) as abnormal glandular cells may originally come from there. Colposcopy assessment is more difficult with atypical glandular cells as sometimes, the abnormality is hidden deep in the tissue or higher up the cervical canal and can be difficult to diagnose.

The Colposcopist will in general, look at the smear at a meeting with the Cytopathologist (the doctors who ‘read’ smears), called a multidisciplinary team meeting or MDT. If they confirm the diagnosis, you will usually be offered a treatment. The treatment can be undertaken as an out-patient procedure, but sometimes the Colposcopist suggests this is undertaken under general anaesthesia and they may consider performing a hysteroscopy [looking at the inside of the uterus (womb) with a telescope] as well in order to check that this is healthy.

You will be told how your results will be sent to you and you may be asked to return for a follow-up discussion. If the histology (tissue removed from the cervix) shows CGIN (cervical glandular intraepithelial neoplasia), then if you still wish to have children, you will have regular follow-up in the Colposcopy clinic.

if your family is complete, your colposcopist will discuss the results with you and you may wish to consider a hysterectomy in order to prevent the glandular abnormality for re-occurring.

Women who have had treatment for glandular abnormalities will not be part of the new follow-up after treatment HPV test, as this may not always be as accurate as in those with follow-up after treatment of squamous abnormalities.

This will depend on the smear test result. If you have had just one abnormal smear with a low grade abnormality it might get better by itself and colposcopy might not be necessary - you will simply need to have the smear test repeated three months following the pregnancy. It is important to remember that pregnancy has no adverse effect in the progression of abnormal cells (CIN) or the development of cervical cancer.

If a colposcopy has been recommended and an appointment has been made with a colposcopy clinic then you should attend. Colposcopy will not in any way harm the pregnancy and can provide valuable and reassuring information. In many cases treatment and even biopsy can be deferred until after the pregnancy. It is very important though, to follow through with the suggested plan, to make sure you return to having normal smear tests

Treatment for cervical cancer depends on the stage (where the cells are located). Treatment for early stage cervical cancer is likely to be with loop excision. Cancer may or may not have been suspected from your cervical smear or colposcopy, but the colposcopist will call you back to clinic and explain the findings. Sometimes no further treatment is necessary but the microscopic findings will be confirmed at a meeting of specialists called a multisciplinary team (or MDT) meeting. Your specialist will discuss the findings of this meeting with you.

You may be referred to a cancer specialist or gynaecological oncologist at another hospital. They may wish to perform an MRI scan, before deciding if you need further treatment. The pelvic lymph glands or lymph nodes that normally deal with infection can be a site of spread or metastatic disease and sometimes your surgeon will recommend that these should be removed with an operation called a lymphadenectomy. This can be performed as a laparoscopic or keyhole procedure.

If you wish to have children, a radical trachelectomy may be discussed with you if this is a suitable alternative for treatment. The cervix is removed either from the vagina or using an abdominal scar and the pelvic lymph nodes are removed. A stitch is placed around the cervix to help support it during a pregnancy, but your surgeon will warn you that late miscarriage and premature delivery are possible and delivery of your baby would have to be by Caesarean Section. The microscopic appearance of the tumour will be examined whilst you are asleep and sometimes the surgeon will need to proceed immediately to hysterectomy despite any earlier plans. This is discussed with you before undergoing the operation.

A radical hysterectomy may be discussed from the outset again depending on the stage. This is usually performed using an abdominal scar, but sometimes can be performed laparoscopically (keyhole surgery) and is a slightly bigger operation than a standard hysterectomy mentioned in ‘Is a hysterectomy the answer?’ The ovaries do not have to be removed, but this would be recommended if you are close to or have had your menopause.
Pelvic radiotherapy or chemoradiotherapy is usually offered for more advanced disease and may be offered at a different hospital again. This would be discussed with your cancer surgeon or clinical oncologist (radiotherapy doctor). Radiotherapy or chemoradiotherapy may also be offered following surgery if risk factors are identified in the microscopic report that indicate you are at increased risk of the tumour recurring. This is called adjuvant treatment and is discussed by the specialists at their cancer MDT meeting.

Occasionally chemotherapy may be offered before, following or in place of surgery and this depends upon the tumour type on microscopic examination of the initial biopsy. Again this would be discussed with you by your cancer team.

HPV vaccines can prevent HPV infection against specific vaccine types. There are two vaccines currently available and both are clinically effective against persistent HPV 16 & 18 infection. This provides protection against just over 70% of high risk types of HPV and associated CIN. The vaccine is given in three doses in a school based programme in the UK with over 80% of those offered vaccination taking it up. It needs to be given before any HPV infection and seems to offer long term protection. When these young women enter the screening programme it will be important that they continue to be screened as not all cervical precancerour will be prevented by vaccination alone