Lesions on the cervix

What Is a Precancerous Cervical Lesion?

One of the best ways to prevent cervical cancer is to have regular Pap tests, which can detect a precancerous cervical lesion so that it can be removed before it becomes cancer. Pap tests take a sample of your cervical cells for examination in a lab. If the results of this cervical cancer screening test are abnormal, you may have changes in the cells of your cervix that could indicate a precancerous cervical lesion.

A precancerous cervical lesion, which is also called an intraepithelial lesion, is an abnormality in the cells of your cervix that could eventually develop into cervical cancer.

There are two main types of cervical cells, squamous and glandular, and abnormalities can occur in either type. The most common types of precancerous cervical lesions include:

  • Atypical squamous cells. If your doctor tells you that you have atypical squamous cells, it means that abnormalities have been detected in the squamous cells of your cervix. This can indicate that you have a human papillomavirus (HPV) infection, another infection, or possibly precancerous cells of another cause. Your doctor may recommend further testing to determine what the abnormalities mean for you. In some cases, this may simply mean a repeat Pap test in a few months. A Pap test with this kind of finding may be reported as “atypical squamous cells of uncertain significance,” abbreviated as ASCUS.
  • Squamous intraepithelial lesion (SIL). This lesion means that you have changes on your cervix that may be precancerous. SIL lesions are classified as either low-grade (LSIL) or high-grade (HSIL), with high-grade lesions being more likely to progress to cervical cancer.
  • Atypical glandular cells. These signal a possible precancerous lesion in the upper area of your cervix or inside the uterus.

Testing and Treating a Precancerous Cervical Lesion

A Pap test screens for cancer or a precancerous condition; it is not used to diagnose a condition. So if your Pap test indicates that you might have a precancerous cervical lesion, your doctor probably will recommend further testing. The screening recommended for you depends on a number of factors, including your age, menopausal status, Pap test results, and whether you are pregnant. Follow-up testing may include one or more of the following:

  • Repeat Pap test. Some women just need another Pap test within a few months to see if the abnormality is still present.
  • HPV testing. Since many abnormalities are caused by an HPV infection, your doctor may recommend that your cervical cells be tested for HPV. Some types of HPV infection clear on their own and don’t tend to cause precancerous changes or cancer, but others, if not cleared by the body, are more likely to cause cancer.
  • Colposcopy. This test allows your doctor to get a better look at your cervix through a magnifying device.
  • Cervical biopsy. This involves removing a small sample of your cervical tissue and sending it to a lab for testing.
  • Endometrial sampling. This involves taking a sample of your endometrium, or uterine lining, for study in a lab.

If this testing determines that you do, in fact, have a precancerous cervical lesion, there are treatments that can help reduce the chances that the lesion will develop into cervical cancer. Treatment options for a precancerous cervical lesion include:

  • Loop electrosurgical excision procedure (LEEP). A thin, electrically charged wire is used to remove abnormal lesions from your cervix.
  • Freezing (cryotherapy). Some precancerous cervical lesions can be destroyed by freezing them with a cold probe; this causes them to eventually shed from your cervix.
  • Laser treatment. The precancerous cervical lesion is destroyed with a beam of laser light.
  • Conization. A small, cone-shaped piece of tissue containing the abnormal area of the cervix is removed surgically.

It can be scary to find out that you have a precancerous cervical lesion, but keep in mind that having a lesion does not mean that you will get cervical cancer. In fact, early treatment of a precancerous cervical lesion can almost always help women avoid getting cervical cancer.

Cervical Dysplasia Treatment

Surgical Treatments

If your doctor determines that you have a high grade cervical lesion, he or she may advise you to have the lesion removed. The two most common methods of removing cervical lesions are by procedures called a LEEP or Cold Knife Cone. Both procedures are quick and typically have a quick recovery time.

The LEEP (Loop Electrosurgical Excision Procedure) can be performed either in the doctor’s office or as an outpatient procedure in the operating room. The procedure starts much like a regular pelvic exam. You will need to lie down on an examining table and put your feet in the stirrups. Next, an instrument called a speculum is inserted into your vagina to hold your vaginal walls open so your physician can view the inside of the vaginal walls and the cervix. A dilute vinegar solution is applied to the cervix to make the abnormal cells visible. An instrument called a colposcope will be used to visualize the cervix. The cervix is numbed with local anesthesia. An electrically charged loop made of thin wire is inserted through the speculum and up to the cervix. As the loop is passed across the cervix, it cuts away a thin layer of surface tissue, removing the abnormal cells. This tissue is then sent to the lab to be tested for abnormal cells. In some instances, a medicated paste is applied to the area to prevent bleeding. If all of the abnormal cervical tissue is removed, no further surgery is needed, though abnormal cells may recur in the future.

Your doctor will give you instructions for recovering at home, including using pads to collect any discharge, avoiding strenuous activity for 48 hours, and abstaining from sexual intercourse for three to four weeks. You also should avoid tub baths, tampons or douching. Over the counter pain relievers can be used to relieve cramping.

The Cold Knife Conization is performed in the operating room, using a scalpel. You will be sedated using anesthesia. You will lie on a table and place your feet in stirrups to position your pelvis for examination. An instrument called a speculum will be inserted into your vagina to hold your vaginal walls open so your physician can view the inside of the vaginal walls and the cervix. The doctor will cut out a small, cone-shaped sample of tissue from the cervix. Pathologists will examine it under a microscope for any signs of cancer or abnormal cells. The procedure may be used to treat moderate to severe dysplasia (CIN II or III). Very early stage cervical cancer (stage 0 or IA1) may also be treated with this procedure. Abnormal cells from the cervical canal, including adenocarcinoma in situ, may be diagnosed, and sometimes treated with cold knife conization.

Your doctor will give you instructions to prepare for the procedure and recover at home. Before the procedure, you may need to fast for six to eight hours. For two to three weeks after the procedure, you may have heavy, bloody, or a yellow-colored discharge. You may experience some cramping or discomfort for a week or so. Avoid sexual intercourse, douching and use of tampons for about four to six weeks.

Therapeutic HPV Vaccines

Through the efforts of a team of investigators in the Johns Hopkins Center for Cervical Dysplasia, several clinical trials testing immune therapies for HPV disease are currently open. The development of these HPV-targeted immune therapies, chronicled in over 20 publications in leading biomedical research journals, emerged from a team of translational investigators in three different disciplines: immunology, gynecologic pathology, and gynecology. The initial generation of HPV vaccines involved the use of targeting signals that made HPV antigens more visible to the immune system. In animal models, these vaccines made strong immune responses against HPV. In addition, strategic collaborations with a number of companies are paving the way to the development of combination immunotherapies with even greater potential efficacy. It is our goal to develop a combinatorial HPV immunotherapy approach that could be applied to all women with established HPV infections, that would ultimately eliminate the need for the complex and expensive screening, long-term follow-up, and surgical interventions currently employed to manage HPV disease. The identification of specific HPV antigens makes this disease an ideal model to develop antigen-specific immunotherapies for other chronic viral diseases, such as hepatitis, and ultimately, non-virus-associated cancers.

Squamous Intraepithelial Lesion (SIL)

Squamous Intraepithelial Lesion (SIL) is the abnormal growth of squamous cells on the surface of the cervix.

The cervix is the lower part of the uterus. Both the uterus and the cervix are located in the pelvis and are close to the upper part of the vagina and the ovaries. In fact, the cervix connects the uterus and the vagina. The vagina leads to the outside of the body.

The surface of the cervix is made up of two different types of cells:

  • squamous epithelial cells (the lining cells of the outer part of the cervix, or ectocervix)
  • columnar epithelial cells (the lining cells of the inner part of the cervix, or endocervix)

Early detection and treatment of precancerous cells can prevent them from becoming cancerous. Otherwise, the abnormal cells can become cancer and spread to other parts of the body.

Pap tests

Pap tests can detect precancerous and cancerous conditions by collecting cells from the surface of the cervix. Sometimes these cells appear abnormal, or atypical, when looked at under a microscope, but they are not completely cancerous. These are called premalignant or precancerous cells, which means they might turn into cancer if not found and treated early enough.

These precancerous lesions are commonly called cervical intraepithelial neoplasia (CIN). They have also been called squamous intraepithelial lesions (SIL) and there are two types:

    Low-grade SIL – the changes are thought to be just starting. The changes can be in the size, shape, or number of cells that are on the surface of the cervix. In these low-grade lesions, the cells have only a few abnormal characteristics, but are still somewhat similar to the normal cells. Other common names for this low-grade SIL are mild dysplasia or cervical intraepithelial neoplasia type I (CIN 1).

    High-grade SIL – the cells look very abnormal under the microscope. However, these cells are still only on the surface of the cervix. They are not invading the deepest parts of the cervix yet. These lesions are also called moderate or severe dysplasia, CIN II or III or carcinoma in situ (CIS).

Please note: Carcinoma in Situ is a term used for the early stage of cancer in which the tumor is confined to the organ where it first developed. The disease has not invaded other parts of the organ or spread to distant parts of the body. Most in situ carcinomas are highly curable.

Treatment Options for Squamous Intraepithelial Lesion (SIL)

Women diagnosed with SIL are seen in our Colposcopy Clinic. For more information, please call 734-763-6295 (Monday-Friday, 8am-5pm EST).

Still have questions?

The nurses at Cancer AnswerLine™ have answers. Call 1-800-865-1125 and you’ll get a personal response from one of our registered nurses, who have years of experience in caring for people with cancer.

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HPV, cervical dysplasia and cervical cancer

Summary

Cervical dysplasia is an abnormal change in the cells of the cervix in the uterus. Early changes, called low-grade lesions by doctors, may persist and develop into high-grade lesions that can lead to cervical cancer. Mildly abnormal cervical cells will usually clear up on their own. Both cervical dysplasia and cervical cancer can be best treated effectively when they are caught early. A sexually transmitted virus called HPV (human papillomavirus) causes most cervical dysplasia and all cervical cancers. Cervical dysplasia is common in HIV-positive people who have a cervix. However, among HIV-positive people living in high-income countries who get regular gynecological monitoring and care, cervical cancer is not common.

The words we use here – CATIE is committed to using language that is relevant to everyone. People use different terms to describe their genitals. This text uses medical terms, such as vagina and penis, to describe genitals. Cisgenderi people can often identify with these terms. Some transgenderii people may use other terms, such as front hole and strapless. CATIE acknowledges and respects that people use words that they are most comfortable with.

Key messages on HPV for clients are available here.

Dysplasia and cancer of the cervix

The cervix is the opening of the uterus (womb) that leads into the vagina. The cervix can be felt with the tip of a finger inside the vagina.

In cervical dysplasia, abnormal cells develop on the surface of the cervix. These abnormal cells are called lesions. Cervical dysplasia lesions can regress (which means they shrink and may even disappear), persist (the lesions remain present but don’t change), or progress to become a high-grade lesion or cervical cancer.

Cervical cancer is an abnormal growth of the cells of the cervix. Over a number of years, abnormal lesions on the cervix can slowly turn into cancer.1–3

What causes cervical dysplasia and cancer?

Cervical dysplasia and cancer have been linked to a very common virus called human papillomavirus (HPV). There are over 100 strains of HPV, about 40 of which can be transmitted sexually. Some strains cause warts, including genital warts (abnormal growths on the skin), some lead to cancer of the genitals or anus, the intestines or the lungs, throat and mouth. Some have no known effect.

The immune system helps protect against the development of cervical dysplasia and cancer. People whose immune systems are weakened by transplant drugs or illnesses such as HIV are at greater risk for HPV infection, cervical dysplasia, and cervical cancer. Women and transgender men who have HIV are at higher risk, and this risk seems to increase as the CD4 counts drop.

Although HPV is necessary for cervical cancer, other factors contribute to the development of cervical dysplasia and cancer. Cigarette smoking has been linked to this condition. Cancer-causing chemicals in cigarette smoke concentrate in cervical fluids and these can affect the health of cervical cells, increasing the risk that these cells become abnormal. Having had a prior sexually transmitted infection (STI), having been pregnant many times, or eating a poor diet can also increase the risk of cervical dysplasia and cancer. Because HPV is sexually transmitted, having multiple sexual partners will increase a person’s risk of being exposed to this virus. However, even people with few partners are still at risk of being infected by HPV.3–6

Symptoms

Usually, there are no symptoms of cervical dysplasia. Genital warts are a sign that someone has been exposed to certain types of HPV, which are different from the types that are most likely to lead to cervical dysplasia and cancer. It is important to note that people can have HPV and not have genital warts or any other symptoms.

Similarly, there are often no physical symptoms of cervical cancer, especially in the early stages. In advanced stages of cervical cancer, there may be pain in the abdomen or lower back, pain or bleeding while having vaginal intercourse, unusual vaginal discharge, or bleeding between menstrual periods.2,3

Diagnosis—Pap smears and colposcopy

Regular pelvic examinations including Pap tests and HPV testing can help diagnose or monitor HPV, cervical dysplasia or cancer. To do a Pap test, the doctor inserts a tiny brush and a small wooden spatula into the vagina and rubs them over the cervix to loosen and collect cells. The cells are smeared on a glass slide that is sent to the lab for study. The Pap test helps identify abnormal cells. For people with HIV, Pap tests are usually done twice during the first year after HIV diagnosis, followed by once a year if the first two tests showed normal results. However, many physicians with HIV-positive people in their care recommend doing a Pap test every six months.

Although Pap tests are useful, they can produce “false-negative” results. In other words, the lab may report a test result as “normal” when there actually are changes in the cells of the cervix. This is the reason why HPV testing is being used more and more in addition to Pap tests. For HPV testing, doctors can collect a small amount of fluid from the cervix and have it tested for the presence of HPV.

Many doctors recommend that people with a cervix who have been newly diagnosed with HIV have a colposcopy. A colposcope is a microscope that looks into the vagina, which has been opened by a speculum, and allows the doctor to visually examine the cervix. The cervix is lightly washed with a weak vinegar solution before the colposcope is put in place. The vinegar solution makes abnormal cells stand out more clearly against the surrounding tissue.

When a colposcopy is performed, a biopsy (removal of a tiny piece of tissue from the cervix) and sometimes an endocervical curettage (the scraping of tissue from the cervix) will be done by the doctor. This procedure can be somewhat painful or cause cramps. The biopsy sample allows lab technicians to study the tissue and confirm the status of cervical tissue.

Pap tests are done by family physicians and gynecologists as part of regular medical care. However, colposcopies and biopsies are done mostly, but not exclusively, by gynecologists.

An HIV-positive person with signs of abnormalities on the cervix, vagina, or vulva should also have an anoscopy, or visual inspection of the anus and anal canal using a microscope similar to a colposcope. This is because the cell changes caused by HPV can also occur in the anus and lead to anal dysplasia.1,7

Test results

The results of tests for cervical dysplasia can be described by a variety of medical terms.

Pap test results

Here are some of the most common test results:

  • Normal: There is no evidence of abnormal changes in the cells sampled.
  • ASCUS (Atypical Squamous Cells of Undetermined Significance): The cells are abnormal, but no definite diagnosis can be made. This test result can be caused by a yeast infection, using oral contraceptives, or problems with taking the sample. Usually doctors repeat the Pap test in a few weeks or test for the presence of high risk types of HPV.
  • LSIL (Low-grade Squamous Intra-epithelial Lesion): This result means an acute infection. If it persists for at least two to three visits, it can be assumed that it could lead to cancer.
  • HSIL (High-grade Squamous Intra-epithelial Lesion): This result means more advanced lesions.
  • AGC (Atypical Glandular Cells): These abnormal cells are the precursors of about 20% of cervical cancers. These cells are very difficult to detect.

Biopsy Results

  • Normal: There is no evidence of abnormal changes in the sampled cells.
  • CIN-1 (Cervical Intra-epithelial Neoplasia, grade 1): This result means mild or low-grade dysplasia. If it persists for at least two to three visits, it can be assumed that it could lead to cancer. For this reason, CIN-1 is usually treated.
  • CIN- 2 or CIN-3: This result means severe or high-grade dysplasia. All or almost all of the cells in the sample may be pre-cancerous and indicates the need for treatment in most cases.
  • CIS: CIS stands for carcinoma in situ and means a small area of cancer has been found. Further tests will be done to find out if the cancer is confined to a small area or if it has spread (called invasive carcinoma).

If someone is diagnosed with HPV, partner notification is not required as a public health measure, unlike with a chlamydia, gonorrhea, syphilis or HIV diagnosis.3,6,8,9

Treatment

Treatment for cervical dysplasia and cancer varies from one person to another, depending on the location and size of the lesion or cancer, and whether the lesion is low grade or high grade or whether the cancer has spread to other parts of the body. Whether or not the person wishes to become pregnant also affects treatment decisions. People with cervical cancer may be referred to a gynecologist-oncologist or an oncologist—a doctor who specializes in the treatment of cancer.

There are several ways that cervical dysplasia may be treated:

  • Cryotherapy destroys the lesion by freezing. This procedure can be done in the doctor’s office. There can be some discomfort or pain. After the treatment, spotting and watery discharge are common.
  • Laser treatment destroys the lesion with an intense beam of light. This procedure is often done in a day-surgery clinic. It can be uncomfortable and can cause spotting and discharge afterward.
  • LEEP stands for loop electrosurgical excision procedure. The lesion is surgically removed by an electrical current that passes through a very fine wire loop and cauterizes the cervix at the same time so that it does not bleed afterward.
  • Cone biopsy removes a cone-shaped piece of tissue from the opening of the cervix and can remove a lesion or very small cancer. It is usually done in a hospital with a laser or a scalpel and patients are given an anesthetic. Some bleeding and pain or discomfort is common after this treatment.

There are several treatment options if cancer is confirmed:

  • Surgery may be used to remove cancerous tissue. If the cancer has spread, surgery to remove the cervix and uterus, called a hysterectomy, may be necessary. Sometimes the fallopian tubes, ovaries and lymph nodes from the pelvis are removed at the same time.
  • Radiation therapy is often prescribed for cervical cancer that has spread beyond the cervix. In radiation therapy, high-energy rays are used to kill cancer cells.
  • Chemotherapy may be used by itself or in addition to radiation therapy if the cancer has spread. Anticancer drugs are used in the blood to kill cancer cells.3,7,9

After treatment

Although cervical dysplasia and cancer can be treated successfully, HIV-positive individuals are at high risk for having this cancer reappear. It is important to follow up treatment with regular Pap tests and a colposcopy every three to six months.10

Cervical dysplasia, HIV and ART

Because HIV and HPV are sexually transmitted, HIV-positive people are often co-infected with both of these viruses. HIV weakens the immune system and in HIV-positive individuals, cervical dysplasia is common.

Taking ART (HIV antiretroviral therapy) can reduce the production of HIV, improve CD4 cell counts, and greatly lower the risk of developing many AIDS-related illnesses. ART cannot prevent cervical cancer. However, with regular gynecological exams and Pap tests, studies have found that cervical cancer is not common in these individuals in high-income countries.11

Prevention

Practising safer sex by using condoms or having non-penetrative sex can help reduce the risk of becoming infected with HPV. However, condoms do not completely eliminate the risk of HPV transmission because the virus may be present on skin not covered by the condom. Condoms also reduce the risk of other STIs that contribute to the development of dysplasia and cancer. Stopping cigarette smoking can help reduce the risk of cervical dysplasia and cancer.

Three vaccines against HPV genotypes are available in Canada. Gardasil is approved for use in “females and males aged 9 to 26.” It protects against HPV types 16 and 18, which cause approximately 70% of cervical cancers, as well as HPV types 6 and 11, which do not cause cancer but cause approximately 90% of warts on or around the genitals and anus. Gardasil 9 protects against HPV types 6, 11, 16 and 18 as well as types 31, 33, 45, 52 and 58 which can also cause cancer. Cervarix is only approved for use in “females aged 10 to 25.” It protects against HPV types 16 and 18 only.

In clinical trials with cisgenderi girls and young women, the vaccines have provided a very high level – over 90% – of protection against complications, such as cervical and anal dysplasias and genital warts, related to the HPV genotypes targeted. Indicators of protective effects have lasted for at least 10 years after vaccination in some trials. For either vaccine to work, three doses given over six months are necessary.

The vaccines do not provide protection against HPV that people are already infected with, but provide excellent protection against HPV the person has not been exposed to. Also the vaccines have not been shown to be effective for the treatment of established HPV infection and are not approved in Canada for this use. Gardasil and Cervarix should be avoided in people who are pregnant. Gardasil can be given to people who are breastfeeding, while Cervarix should only be used during breastfeeding when the possible advantages outweigh the possible risks.

It is important to remember that even if someone has received one of the vaccines, they are only protected against the cancer-causing HPV types covered by the vaccine they have received. Regular medical check-ups with pelvic examinations and cervical cancer screening with Pap tests for women and transmen in their 20s and viral testing starting in their 30s are still needed to help all people, regardless of their HIV status, reduce their risk of cervical cancer and watch for signs of cervical dysplasia and cancer.1,3,5,12–15

The bottom line

Cervical dysplasia is not cancer but must be treated to prevent the possibility of it developing into cancer. Cervical cancer is a serious condition, especially for HIV-positive people. The earlier it is found, the better the chances are for successful treatment.

The risk of acquiring HPV, developing cervical dysplasia and cervical cancer may be reduced by:

  • getting one of the HPV vaccines
  • practising safer sex to reduce the risk of HPV infection
  • quitting cigarette smoking
  • getting regular Pap tests and, if appropriate, colposcopies and anoscopies
  • if HIV positive, taking an effective ART combination3,7,10,15

Footnotes

i Cisgender – someone whose gender identity aligns with the sex they were assigned at birth

ii Transgender – an umbrella term that describes people with diverse gender identities and gender expressions that do not conform to stereotypical ideas about what it means to be a girl/woman or boy/man in society .

(Definitions taken from Creating Authentic Spaces: A gender identity and gender expression toolkit to support the implementation of institutional and social change, published by The 519, Toronto, Ontario.)

Credits

This fact sheet was developed in partnership with the Sex Information and Education Council of Canada (SIECCAN).

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