Hysterectomy to prevent cervical cancer

Can a Hysterectomy “Cure” HPV?

Q1. I have the human papillomavirus and I’m going to have a hysterectomy in the winter. My doctor says that I will be rid of the virus afterward because it lives in the cervix. It that true? Do I not need to worry about HPV post-hysterectomy? Can it come back?

— Lorrie, Ohio

HPV (human papillomavirus) is spread through sexual contact and invades the cells of the vagina and cervix. Most women clear the virus without any special form of treatment, since the infected cells are shed from the cervix and vagina. However, in some women the virus is not cleared but rather remains in some of the cervical and vaginal cells. This persistence of HPV increases the risk of developing cervical cancer and, more rarely, cancer of the vagina.

Unfortunately, once you have been infected with HPV, there is no treatment that can cure it or eliminate the virus from your system. A hysterectomy removes the cervix, which means that the risk of developing cervical cancer because of persistent HPV infection will essentially be eliminated. However, since HPV can also persist in cells of the vagina, a hysterectomy does not necessarily render you free of the virus.

As for the risk of reinfection with HPV, because the virus is spread from person to person through sexual contact, and because there are several different strains of HPV, you could become infected with a new strain even after a hysterectomy if you or your partner has sexual contact with other partners. However, because HPV most commonly persists in the cells of the cervix, the chance of developing a new, persistent HPV infection after a hysterectomy is low.

Q2. What are the symptoms of HPV in men? Are they the same as in women? And how can a man be tested for HPV – what tests would you recommend?

The symptoms of HPV in men differ from those in women. Men often have asymptomatic disease (meaning there are no symptoms) — even more commonly than women. That said, the most common sign of HPV in men is penile warts. HPV can also cause anal warts and is a risk factor for anal cancer in men. There is some controversy about whether HPV can also increase the risk for cancer of the tongue in men.

HPV testing in men is done by swabbing the tip of the penis with a special culture swab. This swab is then tested for the virus.

Q3. I’ve heard a lot about HPV lately. What are the common treatments for this virus? Does it go away after treatment or can it come back?

— Rachel, Maryland

HPV, or human papillomavirus, is a sexually transmitted virus. It causes cervical dysplasia (abnormal changes in the cells that line the cervix, which is the opening to the uterus) and results in an abnormal Pap smear. If left untreated, some cases of HPV can progress to cervical cancer.

The most important part of treatment for HPV is getting regular Pap smears so that any abnormal cells can be removed before they become cancerous. This is actually the main treatment for HPV — the elimination of cells on the cervix that are abnormal. This is done by colposcopy, whereby the cervix is examined with a microscope, and the abnormal cells are removed by means of a biopsy. If the abnormal Pap persists, the entire abnormal region of the cervix can be removed in a procedure called a cone biopsy. While some cases of HPV infection disappear spontaneously, most persist.

A new vaccine, called Gardasil, can now protect women against HPV. It is given in three parts and is very effective. However, the vaccine must be given to a woman before she becomes sexually active in order to protect against HPV. This is why it is currently recommended for girls and young women between the ages of 11 and 26.

Q4. I had HPV some years ago. I had it removed by laser, and my Pap tests have been fine since. Then I had a complete hysterectomy. Now that there is a vaccine against HPV, should someone like me get it? Can the virus come back and lead to cancer, even though I’ve had a hysterectomy?

— Marie, Kansas

The human papillomavirus (HPV) infects the cells of the cervix during sexual activity. While 70-90 percent of these infections go away without treatment, (mostly through shedding of the cells on the surface of the cervix and vagina), the virus may persist in 10-30 percent of cases. When the virus persists, there is an increased risk for cancer (cervical cancer and vaginal cancer) and genital warts, though it generally takes about ten years from the time of infection with the virus to the development of an HPV-related cancer.

It’s most likely that you were infected with HPV many years ago. The abnormal cells on your cervix were probably discovered during your Pap smear, which was being done as a standard screening test for cervical cancer. The discovery of abnormal cells on your Pap smear would prompt testing of the smear for HPV to help determine whether the abnormal cells were of high or low risk. A positive HPV test would be evidence that your abnormal cervical cells were at somewhat high risk of becoming cancerous, and so laser surgery was recommended. Subsequently, it sounds as if you had your uterus and cervix completely removed. You may want to confirm with your doctor that you in fact had a “total hysterectomy” (in which the cervix is removed), as opposed to a “subtotal hysterectomy” or a “supracervical hysterectomy”— these are surgeries in which the uterus is removed but the cervix is left in place. If you no longer have a cervix, and presuming you did not have invasive cervical cancer at the time of your laser treatment or hysterectomy, you cannot develop cervical cancer now. However, that does not change the fact that you have been infected with HPV. You should discuss with your doctor what type (or types) of HPV you were infected with, so that you can be appropriately followed. The higher-risk types are HPV serotypes 16, 18, 11, and 6.

Unfortunately, the vaccine against HPV probably won’t be of much help to you. It is designed to protect women from becoming infected with the high-risk types of HPV, so it’s most appropriate for women who have never been infected with the virus. Since you have already had HPV, and abnormal cells were probably found on your cervix, this vaccine will not be beneficial — it cannot clear up an already-established infection or reverse abnormal changes in the cells of the cervix.

Learn more in the Everyday Health Sexual Health Center.

Human Papillomavirus, HPV

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Overview

If the three letters H-P-V make you recoil, they shouldn’t. Chances are, you have been infected by one or more types of the human papillomavirus (HPV) and didn’t even realize it. In fact, according to the U.S. Centers for Disease Control and Prevention (CDC), most people will become infected by at least one type of HPV at some point in their lives. The CDC reports that 79 million people are currently infected with HPV.

The good news is, in most cases, HPV causes no symptoms or health problems and goes away on its own. HPV is a skin cell virus with more than 100 identified types. That includes low-risk types that may cause genital warts and high-risk types that may cause precancer and cancer.

If HPV causes cells to become abnormal, most return to normal on their own. However, when high-risk types of HPV persist, precancer and cancer may occur. The American Cancer Society estimates that about 13,170 cases of invasive cervical cancer will be diagnosed in the United States in 2019, killing about 4,250 women.

HPV is the cause of nearly all cases of cervical cancer, but cervical cancer is preventable. Screening by Pap and HPV testing can detect precancerous changes that can be treated to prevent cancer from developing.

HPV can also lead to anal cancer in both men and women, a cancer that affects about 5,530 women and 2,770 men per year and causes 760 deaths in women and 520 in men and is on the rise. Notably, anal intercourse is not required for HPV to infect the anal skin cells.

Other health problems can result from HPV infection as well, including genital warts; recurrent respiratory papillomatosis, a rare condition where warts grow in the throat of babies who have been delivered through the birth canal of a mother with genital warts; and other less common but potentially serious cancers, including cancer of the vulva, vagina and penis, and oropharyngeal cancer, a type of head and neck cancer that affects the back of the throat, base of the tongue and the tonsils.

The HPV family of viruses is called papillomavirus because they tend to cause warts, or papillomas—benign (noncancerous) tumors. There are more than 150 strains of HPV and at least 40 HPV types that can infect the anus or genitals. Warts may appear on the hands and feet or on the genital and anal areas. The strains of HPV that cause warts to grow on hands and feet, however, are rarely the same type that cause warts in the genital and anal areas.

The high-risk HPV subtypes most likely to cause cancer are HPV-16, HPV-18, HPV-31, HPV-33, HPV-45, HPV-52 and HPV-58. HPV-16 and HPV-18 cause 70 percent of cervical cancer and HPV 16 causes 90 percent of anal cancer. (HPV 16 is also seen as a cause of some oropharyngeal cancers.)

Two types of HPV—HPV 6 and 11—cause 90 percent of genital warts, though they have almost no risk of causing cancer and therefore are commonly referred to as low-risk types.

There is currently one HPV vaccine approved by the U.S. Food and Drug Administration (FDA), called Gardasil 9, which can protect women against the HPV types that cause most cervical cancers. Gardasil 9 also protects women against vaginal and vulvar cancers and protects both men and women against most genital warts and anal cancers. (See Prevention section for more information.)

In addition to the HPV vaccine for primary prevention, the Pap test and the HPV test are important screening tools to prevent cervical cancer in women. When combined with a Pap test in women age 30 and older, the HPV test is better at identifying women at risk for developing cervical cancer than the Pap test alone. The HPV test is also approved by the FDA to be done alone for women 25 and older, however, most medical organization guidelines call for its use alone in women 30 and older. (See Diagnosis section for more information.) There is no FDA-approved HPV screening test for men.

Because of early detection and treatment of cell changes, the death rate for cervical cancer has decreased by more than 50 percent over the last 40 years.

Conversely, the number of new anal cancer cases has been steadily rising, with most cases occurring in adults. The average age at diagnosis is in the early 60s. Anal cancer affects women more often than men.

How does HPV spread?

HPV spreads via skin-to-skin contact with an HPV-infected area. Infections can be subclinical, meaning the virus lives in the skin without causing symptoms. Hence most people with HPV do not know they have it or that they could spread it. For a person exposed to a partner who has a low-risk genital wart–causing strain of HPV, such as HPV 6 or 11, it takes about six weeks to three months for genital warts to appear. However, most people who are infected by HPV 6 and 11 do not develop genital warts. The most common HPV infections are by high-risk types, and there are no visible symptoms. These infections can only be detected on HPV tests or because of abnormal cell changes detected on Pap tests.

Condoms don’t always protect against the virus because the virus can grow on areas of the genitals not covered by a latex barrier.

It is thought that HPV 6 and 11 may be more easily spread to partners when genital warts are present then when they have been cleared. Therefore, avoiding contact with a new partner until warts are cleared is recommended. HPV most easily gets to the female cervix through penetrative intercourse; however, any skin-to-skin contact may allow the virus to spread.

Diagnosis

Because human papillomavirus (HPV) infections often cause no symptoms in men or women and are hard to identify, you must see a health care professional for diagnosis.

Genital warts are the least common problem caused by HPV infection. They can be flesh-colored and hidden inside the cervix, vagina, penis, scrotum or anus. They can be small or large, alone or in clusters, flat or round. They can spread along the groin or thigh or be found in the mouth.

Genital warts are a visible change caused by HPV. They can be seen with the naked eye and are on the surface of the skin.

The more common change from HPV are lesions of the cervix that are not visible to the naked eye and are detected through screening with Pap and HPV testing. These changes, called squamous intraepithelial lesions, are not visible to the naked eye and are only visible after vinegar has been applied to the cervix and the clinician looks through a microscope. This is called colposcopy. The screening by Pap and HPV tests identifies women who may have these lesions and need a closer look at the cervix through the colposcope.

Specific HPV types cause genital warts, known as condyloma acuminata. Each HPV type has been numbered and divided into high-risk or low-risk categories depending on whether the virus is associated with the development of cancer.

For example, HPV types 6 and 11, which are usually associated with genital warts, are considered low-risk. HPV types 16, 18, 31, 33, 45, 52 and 58, found on the genitals and in the anus, have been linked to most HPV-related cancers in both men and women and are therefore considered high-risk.

If you notice warts, see your health care professional. You should also seek an examination if:

  • You see any unusual growths, bumps or skin changes on or near the penis, vagina, vulva or anus.

  • You see any raised growth on the genital skin that is red, white or darkly pigmented as that could be precancer and should be evaluated by your health care professional.
  • You experience unusual itching, pain or bleeding in the genital or anal area.

  • You have a sexual partner who tells you that he or she has genital HPV or genital warts.

Sexual history does not determine the need or frequency for screening by Pap and HPV testing. Established guidelines apply to all women regardless of sexual history.

All women should have cervical cancer screening, according to guidelines. The Pap test is a simple procedure. For a Pap test, a health care professional uses a special brush and/or spatula to collect cells from the cervix and places them on a glass slide or in a liquid preservative, which is then sent to a laboratory for evaluation. When the sample is sent in the liquid vial, the remaining liquid can be tested for 14 types of HPV, using one of five FDA-approved HPV tests.

There is also an anal Pap test that is much like the Pap test for cervical cancer. It involves swabbing the anal lining and looking at the swabbed cells under a microscope. The anal Pap test is relatively new and hasn’t been studied well enough to determine when, how often and on whom it should be performed, or if it actually reduces risk of anal cancer. Some experts recommend it be done regularly in men who have sex with men.

There are different classifications for abnormal results for the cervical Pap test, but the most common is called atypical squamous cells of undetermined significance (ASC-US). This is a borderline abnormal category and most women with this Pap result do not have abnormal cells. In women ages 21 to 24, a repeat Pap is ordered 12 months later. In women ages 25 to 65, an HPV test will be done to determine whether colposcopy is required or whether a woman needs a follow-up Pap and HPV test in three years. Women with an ASC-US Pap and a positive test for high-risk HPV types will require a closer look at the cervix with the microscope.

Routine follow-up after a negative Pap and HPV is five years.

The other abnormal Pap categories include low-grade (mild) change and high-grade (moderate to severe) change, which is considered precancer.

In conjunction with the Pap test, which screens for abnormal cells once cell changes have taken place, there are tests that look specifically for HPV. These tests can detect the presence of HPV in the cells, which may allow for the detection of abnormal cells that were missed by the Pap and also identifies women with future risk who need to be followed closely as long as the virus persists. There are currently five FDA-approved HPV tests. All but one is able to report the presence or absence of a panel of 12 types of HPV and can genotype specifically for HPV 16 and 18, which cause the majority of cervical cancer. Guidelines for screening and management are different in some cases when HPV 16 or 18 is present.

At this point, HPV tests are also FDA-approved for reflex testing for women whose Pap test reveals ASC-US (borderline abnormal) cells, to determine the need for colposcopy in women who are HPV positive and for cervical cancer screening in combination with a Pap test in women over age 30.

Two tests that report HPV 16 and 18 on every test are now approved for primary HPV testing, which may mean your health care professional will order only an HPV test and not a Pap test initially. If a Pap test result is abnormal, then a colposcopy is recommended. If a Pap test result is not abnormal then an HPV test is repeated in one year. If the HPV test is negative, it is repeated in three years, according to published guidance. In 2018, the U.S. Preventative Services Task Force recommended HPV stand-alone testing with a repeat if negative in five years.

There are currently no recommended screenings or FDA-approved tests that detect HPV infection in men, but research is continuing.

Along with medical history and evaluation of other risk factors, the HPV test helps health care professionals determine what follow-up might be necessary if there is an abnormal result from a Pap test. When a Pap test is high-grade abnormal, the HPV test doesn’t alter the virus management, which is a look at the cervix through the colposcope.

Pap Test Screening Guidelines for Women

The American Cancer Society, the American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend the following guidelines for Pap tests and early detection of cervical cancer:

  • All women should begin screening at age 21.

  • Women ages 21 to 24 should have a Pap test every three years. They should not have an HPV test. If an HPV test is done in the lab and is positive, it doesn’t change the management of borderline and mild abnormal Pap tests. The Pap is repeated in 12 months. High-grade abnormal Pap tests require colposcopy.

  • Women ages 25 to 29 should have a Pap test every three years. If the Pap is borderline abnormal (ASC-US), then an HPV test is used to determine whether that woman should have colposcopy or a three-year follow-up. ASC-US with positive HPV test result requires a colposcopy.

  • Women ages 30 to 65 should have both a Pap test and an HPV test every five years, a Pap test alone every three years or an HPV test alone every three or five years. (The organizations have some variances in preference for type of tests and frequency; talk with your health care professional about what’s best for you.)

  • Women over age 65 who have been screened previously with normal results in the previous 10 years (three Pap tests or two Pap and one HPV tests with no abnormal results) should stop getting screened. Women with cervical precancer should continue to be screened until they have completed 20 years of follow-up.
  • Women who have had a total hysterectomy, with removal of their uterus and cervix, and have no history of cervical cancer or precancer should not be screened. Many women who have had a hysterectomy do not know if they still have their cervix. It should not be assumed that the cervix was removed along with the body of the uterus. If the cervix was left behind, screening should continue according to guidelines.

  • Women who have received the HPV vaccine should still follow the screening guidelines for their age group.

  • Women in special populations including HIV positive, immunosupressed, and DES-exposed are not included in the guidelines for the general population.

If your health care professional identifies any unusual cell changes, he or she will recommend a plan of action, depending on the result and your health history. That may include, a repeat Pap test, an HPV test, or a colposcopy which is a more thorough examination and biopsy of any abnormal area. If the Pap reveals ASC-US and the HPV test is positive, a colposcopy will be the next step. A health care professional will also order a colposcopy if the Pap results signal any other more serious changes.

Further screening and treatments will depend on the results of the colposcopy. In most cases, mild dysplasia (CIN 1) will not be treated, but your health care professional will follow up according to guidelines based on the severity of the screening test. This may include co-testing with Pap and HPV after 12 months, or after 12 and 24 months with any abnormal Pap or positive HPV test leading to a repeat colposcopy. For CIN 2, CIN2,3 or CIN 3, further treatment will be needed to remove the abnormal cells. In young women, CIN 2 or 2,3 may be followed before treatment is done.

Regular age-related cervical cancer screening by Pap and HPV testing is equally important for lesbians and bisexual women who, studies find, may be less likely to seek routine health care because of the discomfort they feel discussing or revealing their sexual orientation to health care professionals. They also may not want to undergo screening because they feel they are not at risk. However, lesbian and bisexual women are also at risk for HPV infection and cervical cancer (for example, through prior male partners, vibrators and other sexual aids or skin-to-skin contact with an infected partner).

Can Vaginal Cancer Be Prevented?

The best way to reduce the risk of vaginal cancer is to avoid known risk factors and to find and treat any vaginal pre-cancers. But since many women with vaginal cancer have no known risk factors, it’s not possible to completely prevent this disease.

Avoid HPV infection

Infection with human papillomavirus (HPV) is a risk factor for vaginal cancer. HPV infections occur mainly in younger women and are less common in women over 30. The reason for this is not clear.

HPV is passed from one person to another during skin-to-skin contact with an infected area of the body. HPV can be spread during sexual activity – including vaginal, anal, and oral sex – but sex doesn’t have to occur for the infection to spread. All that’s needed is skin-to-skin contact with a part of the body infected with HPV. The virus can be spread through genital-to-genital contact. It’s even possible for a genital infection to spread through hand-to-genital contact.

An HPV infection also seems to be able to be spread from one part of the body to another. This means that an infection may start in the cervix and then spread to the vagina and vulva.

HPV is very common, so having sex with even one other person can put you at risk. In most cases the body is able to clear the infection on its own. But in some cases the infection doesn’t go away and becomes chronic. Over time, chronic infection, especially with high-risk HPV types, can cause certain cancers, including vaginal cancer and pre-cancer.

Condom use

Condoms (“rubbers”) provide some protection against HPV. Condoms cannot protect completely because they don’t cover every possible HPV-infected area of the body, such as skin on the genital or anal area. Still, condoms do provide some protection against HPV, and also protect against HIV and some other sexually transmitted diseases.

HPV vaccines

There are vaccines that protect against infection with certain types of HPV. These vaccines can only be used to prevent HPV infection – they don’t help treat an existing infection. To work best, the vaccines should be given before a person is exposed to HPV (such as through sexual activity). These vaccines are approved to help prevent vaginal cancers and pre-cancers. They are also approved to help prevent others cancers, as well as anal and genital warts.

For more information about HPV and HPV vaccines, see HPV (Human Papillomavirus).

Don’t smoke

Not smoking is another way to lower vaginal cancer risk. Women who don’t smoke are also less likely to develop a number of other cancers, such as those of the lungs, mouth, throat, bladder, kidneys, and several other organs.

Find and treat pre-cancers

Most vaginal squamous cell cancers are believed to start out as pre-cancerous changes, called vaginal intraepithelial neoplasia or VAIN. VAIN may be present for years before turning into a true (invasive) cancer. Screening for cervical cancer (such as with a Pap test or HPV test) can sometimes pick up these pre-cancers. If a pre-cancer is found, it can be treated, stopping cancer before it really starts.

Still, since vaginal cancer and VAIN are rare, doctors seldom do other tests to look for these conditions in women who don’t have symptoms or a history of pre-cancer or cancer of the cervix, vagina, or vulva.

How Pap tests and pelvic exams might help find VAIN

Vaginal intraepithelial neoplasia (VAIN; pre-cancer of the vagina) may not be visible during a routine exam of the vagina. But it may be found with a Pap test. Because cervical cancer is much more common than vaginal cancer, Pap test samples are scraped or brushed from the cervix. But some cells of the vaginal lining are usually also picked up at the same time. That allows cases of VAIN to be found in women whose vaginal lining is not intentionally scraped. Still, the main goal of a Pap test is to find cervical pre-cancers and early cervical cancers, not vaginal cancer or VAIN.

In women whose cervix has been removed by surgery to treat cervical cancer or pre-cancer, Pap test samples may be taken from the lining of the upper vagina to look for cervical cancer that has come back, and to look for early vaginal cancer or VAIN. Vaginal cancer and VAIN are more common in women who have had cervical cancer or pre-cancer.

Many women with VAIN may also have a pre-cancer of the cervix (known as cervical intraepithelial neoplasia or CIN). If abnormal cells are seen on a Pap test, the next step is a procedure called colposcopy, in which the cervix, the vagina, and at times the vulva are closely examined with a special instrument called a colposcope.

Ask the experts

My wife had an abnormal pap smear test which resulted in the doctor indicating she had abnormal cells on her cervix. She had a hysterectomy to correct the problem but does this mean she could have developed cancer and does this predispose her to have cancer in the future?
Signed, MQ

Doctor’s response

While we do not know the specific medical details involved in this situation, several general comments can be made about women who have had a hysterectomy for cervix abnormalities. If the hysterectomy was done for dysplasia (see MedicineNet.com’s Pap Smear article), then it may recur in the vagina in about 1-2% of patients who have had hysterectomy. On the other hand, if a radical hysterectomy was done because of cervix cancer, recurrence rate may be up to 9%. Recurrence probably depends somewhat on how advanced the cancer was, and it definitely depends on what type of hysterectomy was performed.

One thing is certain in all women who have had hysterectomy for cervix abnormalities; even though risk of recurrence is pretty low, they need to be screened lifelong for recurrence by having a vaginal sample (vaginal smear) annually, or more often according to the doctor’s advice.

Thank you for your question.

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Ana’s Cancer Survivor Story

I was diagnosed with Stage 2 cervical cancer (adenocarcinoma) at age 36. I was a single mother with two children, ages 6 and 8.

I had abnormal Pap smears starting 8 years prior, when I was pregnant with my daughter. I was never told that I had HPV, even though I did. After each abnormal Pap test result, I would have a LEEP and colposcopy. They always came back clear, and my gynecologist/obstetrician would send me on my way.

And then, I had abnormal bleeding. I thought it was from a poorly placed IUD. I went to my gynecologist, who said, “You know, you have this history, and you have HPV, and so I’m going to do a Pap, but this time I’ll sample cells a little higher up in your cervix.”

I got abnormal results again and scheduled yet another colposcopy for the day before Thanksgiving. I still really wasn’t concerned. I got the results on December 15th, three days before my school’s winter break. My doctor called while I was teaching and said, “I have your results. You have cancer. I can’t treat you, and I have referred you to an oncologist. They will be calling today. You probably will have to have a hysterectomy.” I left work, and sat in my car, in shock. I sat there for maybe 45 minutes before the tears came. I had no idea what to expect. All I knew was I could not die, I had two babies who needed me.

That Christmas was spent going for exams, scans, meeting with oncologists and radiologists, and chemo doctors to set my plan for treatment. On New Year’s Eve, I had my first laparoscopic surgery. The surgeon removed my fallopian tubes and moved my ovaries out of the field of the radiation that I would soon be getting.

Six weeks later, I started weekly chemotherapy appointments and 28 rounds of external radiation. I continued this for six weeks and then had three more rounds of internal radiation. My body was exhausted. We moved in with my parents so they could help get me to appointments and shuttle my kids to and from school and their activities.

And then, in April, it was over. My doctors sent me home, telling me, “You’re done. We will see you in six months.” I was petrified. There was no way to know whether they had gotten all of the cancer. Then I started having a lot of discharge. My radiologist and oncologist told me it was healing due to radiation. They told me to wait a month and it will get better…wait three months and it should be gone. After six months I was done waiting. I knew there was something still wrong.

It was at this point that I went to get my first second opinion. I was worried my gynecologic oncologist would be upset at me for not trusting her. But I knew I needed to advocate for myself. When I got the second opinion, the doctor said, “There is most likely residual cancer.” I couldn’t believe it. I had a radical hysterectomy two weeks later.

After the surgery, I was told that they had gotten clear margins and there was no evidence of disease. Yay! But a few days later, I began having extreme pain in my kidneys. I found out that my ureters (what attaches your kidneys to your bladder) were damaged from radiation on both sides of my body.

In January of 2017, I had major reconstructive surgery on my bladder and ureters. I was sent home with a catheter and stents in both ureters, to aid in the healing process. It was painful and cumbersome. Finally, six weeks later, the stents and catheter were removed.

October 5th, 2017, was my first cancerversary. With a clear PET/CT scan, I was officially one year free from cancer. But my Pap test showed more precancerous cells. This time they were VAIN lesions, vaginal intraepithelial neoplasia, level 2.

Again, I called to get a second opinion on the treatment recommended for me. This time I wasn’t worried about offending anyone. I wanted to advocate for my health and take matters into my own hands. The second opinion confirmed the course of treatment recommended by my oncologist.

Since January 2018, I have been cancer- and lesion-free. I would never choose to go through this battle, but I choose to see the blessings in the experience of having cancer. I learned to listen to my body and advocate for myself. I learned that it’s okay to get a second opinion. I learned that I have countless family and friends who are here to support me, sitting with me during chemo, driving me to radiation, watching my children, cooking meals, laughing with me, crying with me, advocating for me when I didn’t have the ability to do so on my own. And in the case of my mom, doing anything and everything I needed, sometimes even before I knew I needed it. But most of all I learned that I am strong. Every time I thought I couldn’t make it, I couldn’t go on, every time I wanted to give up, I dug deeper. I kept finding more strength.

I want women to know they need to take care of themselves. Don’t skip your annual exams, and if you feel something is amiss with your body, don’t worry about bothering doctors or upsetting them. This is your life! I also want people to know that my generation could potentially be the LAST generation to have cervical cancer. We can eradicate this disease by vaccinating our children, daughters AND sons. This is my mission now: to share my story so that others don’t have to go through what I went through.

Cervical cancer

You should expect to have some vaginal bleeding or discharge for some days after the treatment. It can carry on for up to 4 weeks. How long it lasts depends partly on the type of treatment you’ve had. You may have:

  • light bleeding for days or weeks
  • watery vaginal discharge

You are more likely to have bleeding, and it’s more likely to be heavier, if you have treatment when your period is due. This is why doctors prefer to treat you between periods if possible.

See your GP or contact the colposcopy clinic if you have:

  • discharge that smells unpleasant
  • heavy bleeding or the bleeding lasts longer than 4 weeks

If you have an infection your GP can give you antibiotics.

Sometimes the bleeding gets heavier 10 to 12 days after your treatment. This is probably nothing to worry about. But if it seems heavier to you than a heavy period, you must either contact your GP or go to your local accident and emergency department (A & E).

Your emotions and feelings

These are often overlooked. But many women find that this type of treatment has an emotional effect on them. Some women may feel:

  • anxious
  • distressed
  • depressed
  • vulnerable

This is not really surprising. This is a very private area of your body. The undignified position needed for cervical screening or treatment can upset many women. The colposcopy staff are aware that women can feel like this, and so will try to make you feel as comfortable and at ease as possible.

Usually you get over these feelings with a little time. But if you feel you need help, you can talk to your GP about counselling.

Your privacy and dignity should be protected at all times when you’re having these sorts of investigations and treatments.

If you feel your privacy or dignity were not properly protected, write to the nurse manager of the unit where you were treated. Your suggestions for improving things will help other women in the future and writing it down can also help you to get over your experience.

Some women find that needing to have treatment for abnormal cervical cells really worries them. This condition is often confused with cervical cancer. But even if you are clear about the difference, the experience can make you more worried about cancer of any type.

Your colposcopist or nurse can answer any questions you have and help to reassure you.

Getting back to normal

You should have fully recovered from this type of treatment in about 6 weeks at the most. If you have had a small amount of laser treatment, you will get over it quicker than that.

You shouldn’t have sex before 4 weeks because of the risk of infection. But after any of these treatments, you should be able to have sex and do any work or exercise you wish to within 6 weeks.

Follow up

You are invited back for a follow up screening test about 6 months after treatment for abnormal cervical cells. This may be done at the colposcopy clinic or your GP practice.

It’s very important that you go to this appointment. The chances are that you won’t have any further problems. Treatment is successful in more than 4 out of 5 women. If the abnormal cells do come back you will need to have more treatment.

HPV

The NHS screening programme has brought in testing for the human papilloma virus (HPV) as part of follow up. If your cell sample is normal, or shows borderline or mild cell changes, the sample will be checked for HPV:

  • if no HPV is found, you won’t need to have another screening test for 3 years
  • if HPV is found, or you have moderate or severe cell changes, you go back to the colposcopy clinic to see if you need more treatment

Cervical screening after hysterectomy

You may still need follow up even if you have had a hysterectomy for abnormal cells. The cells for the test are taken from the top of the vagina, near where your cervix was. Your doctor may call this a vault smear.

Very rarely the abnormal cells can come back in this area, so you will be offered tests at 6 months and 18 months after your hysterectomy. If everything is fine, you won’t need to have any more tests after that.

What happens if abnormal cells come back

Usually you can have more laser treatment or a LLETZ. You may need to have a cone biopsy.

But if the abnormal cells come back more than once, or if your doctor thinks the risks are too great, they may ask you to have a hysterectomy. This is to prevent you from developing cancer of the cervix in the future. Your doctor will talk through all the treatment options with you at every stage.

Your wishes will be taken into account when deciding what the best treatment is for you. Your decision may depend on whether you have had all the children you wish to have. Or whether you have reached the menopause.

Some women prefer to have a hysterectomy because they can then be satisfied that all the abnormal cells should have been taken away.

It is usually possible for you to keep your ovaries if you’re having a hysterectomy for this reason, so the operation should not affect your hormones or send you into an early (premature) menopause. If your ovaries are removed before the menopause you may need hormone replacement therapy (HRT).

Pregnancy after treatment

Unless you have had a hysterectomy, no treatment for abnormal cervical cells should make any difference to you getting pregnant in the future. Some of the treatments can lead to a small increase in risk of pregnancy complications.

For example, you may have a slightly increased risk of premature birth in future pregnancies. This means the baby might be born before the 37th week of pregnancy. This is more likely to happen if you’ve had repeated treatments or a lot of tissue removed.

Q&a attempts to provide balanced answers to those curly-yet-common questions in obstetrics and gynaecology for the broader O&G Magazine readership, including Diplomates, Trainees, medical students and other health professionals.

Q

‘What is the role of vaginal cytology after hysterectomy?’

a
Pap smears of the vaginal vault aim to detect invasive or pre-invasive disease of the vagina in women who no longer have a cervix. Vaginal intraepithelial neoplasia (VAIN) is much less common than cervical intraepithelial neoplasia (CIN), with an incidence of 0.2 to 0.3 per 100 000 women.1 Vaginal cancer has an incidence of 0.7 per 100 000 women2, making it a rare gynaecological malignancy.

A recent study on vaginal cytology in women who underwent a hysterectomy owing to gynecological malignancy, CIN 3 or benign gynecological diseases, indicated that VAIN lesions occurred in these groups at a rate of 7.1 per cent, 3.0 per cent, and 0.5 per cent, respectively.3 Given the low prevalence of VAIN and vaginal cancer, available evidence indicates a low positive predictive value for vaginal cytology when used as a screening tool in the absence of symptoms or clinical signs.3,4

Hysterectomy for benign disease

Abnormal cytology is found in less than two per cent of vaginal cuff smears after hysterectomy for benign disease.1,2,3 Collating data from more than 6000 women, Stokes-Lampard et al reported that subsequent to hysterectomy for benign indications, 1.8 per cent of women had an abnormal vaginal vault smear, 0.12 per cent had an abnormal biopsy and no cancers were identified.2

Current recommendations are that women who have undergone hysterectomy for benign conditions at any age, who have a history of normal Pap smears and whose cervical histology shows no dysplasia or malignant change, should not be screened for VAIN or vaginal cancer using any modality as they are at minimal risk. In women where a normal Pap smear history is not available or where histology of the hysterectomy specimen is not available, a baseline Pap smear of the vaginal vault can be performed. If this is negative, further smears are only required as indicated by symptoms.5

Women who have had a subtotal hysterectomy where the cervix remains in situ require ongoing cervical cytology as per national screening guidelines for the prevention of cervical cancer.5

Hysterectomy for cervical dysplasia

Hysterectomy for CIN is a known risk factor for the subsequent development of VAIN, with reported rates ranging from 0.9 to 6.8 per cent.6 In a systematic review, women who underwent hysterectomy for CIN 3 had an incidence of abnormal vault smears of 14 per cent. However, less than two per cent of patients had an abnormal biopsy and only a single case of vaginal cancer was detected (0.03 per cent). 86 per cent of abnormal smears occurred within two years of hysterectomy.2 Shockaert et al detected VAIN 2+ in 7.4 per cent of women who had Pap smears after hysterectomy for CIN 2/3 or Stage 1A 1 cervical carcinoma.6 Women who developed VAIN 2+ after hysterectomy were significantly older than women that did not. The median interval between hysterectomy and biopsy proven VAIN 2+ was 35 months.6 These data would indicate that these women remain at risk of VAIN following hysterectomy for high-grade cervical dysplasia, particularly in the first two years.

This risk of developing subsequent VAIN is largely determined by the adequacy of excision of the CIN or ACIS at the time of hysterectomy. If excision margins are involved with high-grade dysplasia or not adequately assessed by histology of the hysterectomy specimen, there is an increased risk of VAIN or invasive cancer in the region of the vault. Vaginal vault smears and vaginal colposcopy should continue to be performed annually, with directed biopsies if required.5 When a high-grade lesion (CIN 2/3 or adenocarcinoma in situ) has been completely excised at hysterectomy it is reasonable for women to undergo annual vault cytology for five years and if results are normal, thereafter revert to the recommended screening interval.5

Women with previously treated CIN 2/3 who have subsequent normal Pap smears, negative high-risk human papillomavirus (HPV) DNA testing and have no residual disease on histology of the cervix, should continue to have vaginal cytology at the recommended screening interval until such evidence is available to indicate that clearing the HPV virus from the cervix also indicates its clearance from the vagina.5

Women with a history of low-grade CIN who have reverted to normal cervical cytology prior to hysterectomy do not need vaginal vault smears, unless symptomatic.

Hysterectomy for invasive cervical cancer

The vagina is a common site for recurrent cervical and the early detection of these recurrences is aimed at treating patients with potentially curative salvage therapy.

Although most guidelines suggest vaginal cytology after hysterectomy for cervical carcinoma at each follow-up visit7,8, the effectiveness of Pap smears in this context is not well studied. Clinical symptoms and physical examination will detect the majority of recurrences with few cervical cancer recurrences being detected by vaginal cytology alone.9,10,11 Furthermore, the interpretation of cytology can be problematic in those patients who have been treated with adjuvant radiotherapy.

In a review of 13 trials on follow up of cervical cancer, asymptomatic recurrent disease was detected using vaginal vault cytology in 0–17 per cent of cases.12 Injumpa et al showed that the detection rate of vaginal recurrences by vaginal cytology was only 2.4 per cent, with the test having poor sensitivity.13

The majority of cervical cancer recurrences occur in the first two-to-three years after treatment3 and >90 per cent have occurred by five years.12 Li et al in their cohort of women with cervical squamous cell carcinoma, treated with hysterectomy, found that all vaginal high-grade dysplasia and recurrent squamous cell cancers were detected in the first two years of follow up.1

Current surveillance recommendations for women following treatment for cervical cancer include annual vaginal cytology and thorough examination of the vaginal vault to detect local recurrence and pre-invasive disease in the vagina.

The role of high-risk HPV DNA testing in women treated for invasive cervical cancer or high-grade cervical dysplasia after hysterectomy is not clear and requires further investigation.5 With the introduction of new cervical cancer screening guidelines, based on primary HPV testing, due to take place in Australia and New Zealand, we await further monitoring data to advise on the utility of HPV-based testing in the post-hysterectomy population.

Hysterectomy for endometrial cancer

Following treatment of endometrial cancer, approximately three-to-five per cent of patients will experience a local recurrence of disease confined to the vagina and central pelvis11,14 that may be salvaged with curative therapy. More than 80 per cent of these women will present with vaginal bleeding or have a clinically apparent lesion in the vagina.14 Hence, a history of vaginal bleeding and careful visual examination and palpation of the vaginal vault will identify the vast majority of patients that need further evaluation for recurrent disease.

Vaginal cytology alone is ineffective at identifying vaginal recurrences in asymptomatic patients, with less than one per cent of asymptomatic vaginal recurrences are detected by routine vaginal cytology.14,15 Finally, a significant survival advantage has not been demonstrated for patients whose recurrences are detected during routine follow-up visits compared with patients who present for internal examinations owing to the onset of symptoms.14,15

Hence, routine vaginal cytology in asymptomatic women under surveillance after hysterectomy for endometrial adenocarcinoma is no longer recommended.

Other high-risk populations

Women previously treated for VAIN remain at risk and should continue to have vaginal cytology post hysterectomy, every one-to-two years, dependent on patient risk factors, extent of VAIN and completeness of excision. Women with a past history of HPV-related vulval or anal dysplasia or malignancy should also continue to have vaginal cytology at one-to-two yearly intervals.

Similarly, immunocompromised women are predisposed to squamous cell malignancy of the lower genital tract and should be followed up with vaginal cytology every two years and annually if they have a past history of lower genital tract dysplasia.

Women who were exposed to diethylstilboestrol (DES) in utero are at increased risk for clear cell cancer of the vagina and cervix and should continue to have vaginal Pap smears and careful palpation of the vaginal walls at one-to-two yearly intervals after hysterectomy.

In conclusion, vaginal cytology for vaginal cancer screening is advisable for women who have undergone total hysterectomy if they have the following characteristics:

  • prior vaginal high-grade dysplasia or cancer;
  • prior cervical, vulval and anal dysplasia or cancer;
  • CIN 2/3 or cervical adenocarcinoma in situ diagnosed at hysterectomy;
  • in utero exposure to DES; or
  • immunosuppression (for example, HIV, history of solid organ orhaematopoietic cell transplant).

Routine vaginal cytology is no longer recommended in asymptomatic women after hysterectomy for benign conditions or treatment of endometrial adenocarcinoma.

  1. Li Z, Barron S, Hong W, Karunamurthy A, Zhao C. Surveillance for Recurrent Cancers and Vaginal Epithelial Lesions in Patients With Invasive Cervical Cancer After Hysterectomy: Are Vaginal Cytology and High-Risk Human Papillomavirus Testing Useful? American Journal of Clinical Pathology. 2013;14(5):708-14.
  2. Stokes-Lampard H, Wilson S, Waddell C, Ryan A, Holder R, Kehoe S. Systematic review: Vaginal vault smears after hysterectomy for reasons other than malignancy: a systematic review of the literature. BJOG. 2006;113(12):1354-65.
  3. Gupta S, Sodhani P, Singh V, Sehgal A. Role of vault cytology in follow-up of hysterectomized women: Results and inferences from a low resource setting. Diagnostic Cytopathology. 41(9):762-6.
  4. Stokes-Lampard H, Stokes-Lampard H, Wilson S, Waddell C, Bentley L. Vaginal vault cytology tests: analysis of a decade of data from a UK tertiary centre. Cytopathology (Oxford). 22(2):121-9.
  5. RANZCOG College Statement: C-Gyn 8. Cytological follow up after hysterectomy. November 2013. www.ranzcog.edu.au/doc/cytologicalfollow-up-after-hysterectomy.html .
  6. Schockaert S, Poppe W, Arbyn M, Verguts T, Verguts J. Incidence of vaginal intraepithelial neoplasia after hysterectomy for cervical intraepithelial neoplasia: a retrospective study. American Journal of Obstetrics and Gynecology. 2008;199(2):113.e1-.e5.
  7. National Comprehensive Cancer Network. Guidelines for cervical cancer. Available at http://www.nccn.org/professionals/physician_gls/f_guidelines.asp .
  8. American Congress of Obstetricians and Gynecologists. ACOG practice bulletin: diagnosis and treatment of cervical carcinomas, number 35, May 2002. Int J Gynaecol Obstet. 2002;78:79-91.
  9. VanNagell JR Jr, Rayburn W, Donaldson ES, et al. Therapeutic implications of patients of recurrence in cancer of the uterine cervix.Cancer. 1979;44:2354-2361.
  10. Bodurka-Bevers D, Morris M, Eifel PJ, Levenback C, Bevers MW, Lucas KR, Wharton JT. Post therapy surveillance of women with cervical cancer:an outcomes analysis. Gynecol Oncol. 2000;78(2):187.
  11. Santillan A, Govan L, Zahurak ML, Diaz-Montes TP, Giuntoli Ii RL, Bristow RE. Feasibility and economic impact of a clinical pathway for pap test utilization in Gynecologic Oncology practice. Gynecologic Oncology. 2008;109(3):388-93.
  12. Elit L, Fyles AW, Devries MC, Oliver TK, Fung-Kee-Fung M, Gynecology Cancer Disease Site Group. Follow-up for women after treatment for cervical cancer: a systematic review. Gynecol Oncol. 2009;114(3):528.
  13. Injumpa N, Suprasert P, Srisomboon J, Nimmanahaeminda K. Limited value of vaginal cytology in detecting recurrent disease after radical hysterectomy for early stage cervical carcinoma. Asian Pacific Journal of Cancer Prevention. 7(4):656-8.
  14. Bristow RE, Purinton SC, Santillan A, Diaz-Montes TP, Gardner GJ, Giuntoli Ii RL. Cost-effectiveness of routine vaginal cytology for endometrial cancer surveillance. Gynecologic Oncology.2006;103(2):709-13.
  15. Steele E, Umar SA, Bomeisl P, Miedler J. Glandular cells in vaginal cytology Papanicolaou tests in patients with hysterectomy for endometrial adenocarcinoma. Diagnostic Cytopathology. 40(2):138-40.

Vaginal Cancer

Vaginal Cancer Home | General information | Risk Factors | Symptoms
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Risk Factors

Doctors do not know what causes most vaginal cancers. There is no way to predict whether a particular woman will get vaginal cancer. It is possible to develop vaginal cancer without being at high risk, and it is possible to be at high risk and not develop it. However, women who fall into the following groups may be more likely to develop vaginal cancer:

  • Women who have HPV (human papillomavirus), a sexually transmitted disease that can increase the risk of several cancers of the reproductive organs, including vaginal and cervical cancer. In most women, an HPV infection will go away on its own, but for some, it causes cell changes that increase their future risk of cancer.
  • Women who have a history of precancerous vaginal conditions. Precancerous cells in the vagina are called vaginal intraepithelial neoplasia (VAIN). These cells are not malignant, but are different from normal cells. Most women who develop VAIN do not go on to develop cancer, but a few do. VAIN is caused by HPV infection.
  • Women who have had a hysterectomy (removal of the uterus), because this increases the risk of VAIN
  • Women who have been treated for cervical cancer or precancerous cervical conditions
  • Women whose mothers took DES (diethylstilbestrol) to prevent miscarriage, a drug that was often prescribed in the 1950s, when they were pregnant. These women are at risk for a particular type of vaginal cancer, adenocarcinoma.
  • Women who have had multiple sexual partners (which increases the risk of an HPV infection)
  • Women who were unusually young when they first had sexual intercourse
  • Women who have an autoimmune condition, an HIV infection, or any other condition that causes the immune system to work less effectively. A weakened immune system increases a woman’s risk of vaginal cancer by increasing her risk of developing an HPV infection.
  • Women who smoke
  • Women who are older. The average vaginal cancer patient is diagnosed after the age of 60, and a woman’s risk of developing it increases as she gets older. However, vaginal cancer can affect women of any age.

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