- Precancerous conditions of the cervix
- Types of precancerous conditions
- Risk factors
- Cervical cancer
- Precancerous conditions of the uterus
- Surgery for Cervical Cancer
- Surgery for cervical pre-cancers
- Surgery for invasive cervical cancer
- Diagnosing Endometrial Cancer
- Risk Factors
- Pelvic Exam
- Endometrial Biopsy
- Transvaginal Ultrasound
- Hysteroscopy with Dilatation and Curettage
- Additional Imaging Tests
Precancerous conditions of the cervix
Precancerous conditions of the cervix are changes to cervical cells that make them more likely to develop into cancer. These conditions are not yet cancer. But if they aren’t treated, there is a chance that these abnormal changes may become cervical cancer. If left untreated, it may take 10 years or more for precancerous conditions of the cervix to turn into cervical cancer, but in rare cases this can happen in less time.
Precancerous conditions of the cervix happen in an area called the transformation zone. This is where columnar cells (a type of glandular cell) are constantly being changed into squamous cells. The transformation of columnar cells into squamous cells is a normal process, but it makes the cells more sensitive to the effect of the human papillomavirus (HPV).
Types of precancerous conditions
Precancerous conditions of the cervix are described based on how abnormal the cells look under a microscope and how severe the cell changes are. They are grouped based on the type of cell that is abnormal. Precancerous changes in the cervix are quite common.
Abnormal squamous cells
Most doctors describe abnormal changes to squamous cells in the cervix using the Bethesda reporting system, which refers to squamous intraepithelial lesion (SIL). Other reporting systems refer to cervical intraepithelial neoplasia (CIN) and cervical dysplasia.
SILs are divided into low grade and high grade. CIN is graded as 1, 2 or 3.
Low-grade SIL (LSIL) compares to CIN 1. LSIL only affects cells on the surface of the cervical lining or close to it. The cervical dysplasia is mild, with changes to the cells looking only slightly different from normal cells.
High-grade SIL (HSIL) compares to CIN 2 and CIN 3. Changes to cells are deeper in the cervical lining. The cervical dysplasia is moderate to severe and the cells are considered more abnormal.
With HSIL, there are distinct changes to the size and shape of the cells so they look different from normal cells. CIN 2 is moderate to severe dysplasia. CIN 3 is severe dysplasia and also includes carcinoma in situ classification. The higher the grade the higher the risk of cancer.
Abnormal glandular cells
Atypical glandular cells (AGC) and adenocarcinoma in situ (AIS) are changes to glandular cells in the cervix. Glandular cell abnormalities are not graded and are described using the Bethesda reporting system.
AGC means the cells don’t look normal. Changes to cells are linked with a higher risk of becoming cancer or may mean that there is an underlying cancer.
AIS means pre-invasive cancer cells are found. This means they haven’t spread into the deeper tissues of the cervix or surrounding tissue.
Infection with the human papillomavirus (HPV) is the main risk factor for precancerous changes in the cervix. Smoking and having a weakened immune system increase the chance that an HPV infection will not go away on its own and will develop into a precancerous condition of the cervix.
Precancerous changes in the cervix usually don’t cause any signs or symptoms. An abnormal Pap test result is often the first sign that some cells in the cervix are abnormal. This is why it is important to have regular Pap tests.
If a Pap test result is abnormal, you will have more tests to rule out or diagnose a precancerous condition or cervical cancer. Tests may include:
- another Pap test after a few months (usually 6 months) if there are mild changes
- an HPV test, which can sometimes be done on a sample of cervical cells taken during a Pap test
- a colposcopy exam and biopsy of any abnormal-looking areas
- an endocervical curettage, which removes cells from the endocervical canal and is usually done at the same time as a colposcopy
Find out more about a Pap test, a colposcopy and a biopsy.
Most women treated for precancerous conditions of the cervix have an excellent outcome and their condition won’t develop into cervical cancer.
Mild changes to the cervix often return to normal on their own without any treatment.
More severe abnormalities are more likely to develop into cervical cancer, especially if they aren’t treated for a long time. It is hard to predict which of these will become invasive cervical cancer, so they are usually treated as soon as they are diagnosed.
Treatment options for precancerous changes in the cervix may include:
- loop electrosurgical excision procedure (LEEP) or other cone biopsy procedure
- laser surgery
LLETZ stands for large loop excision of the transformation zone. It’s also known as loop electrosurgical excision (LEEP) or loop diathermy. This is the most common treatment for abnormal cervical cells.
Your colposcopist uses a thin wire loop to remove the transformation zone of the cervix. The wire has an electrical current running through it, which cuts the tissue and seals the wound at the same time.
The transformation zone is the area around the opening of the cervix.
LLETZ is an outpatient treatment and takes up to 15 minutes. You usually have it under local anaesthetic.
At the colposcopy clinic, your nurse asks you to undress from the waist down and then to lie on your back on the examination couch. They give you a sheet to cover yourself. Your legs are supported by 2 leg rests.
Your colposcopist gently puts a medical instrument called a speculum into your vagina to hold it open (like when you have a cervical screening test). They look through the colposcope to examine your cervix.
They inject some local anaesthetic into your cervix. This might sting for a short time. The local anaesthetic numbs the area. Your colposcopist can then remove the area of tissue with the abnormal cells. This is not painful but you may feel some pressure.
Your colposcopist then removes the speculum and you can get dressed when you’re ready.
You should bring a sanitary towel with you to the hospital. You’ll need one after the treatment as there might be some bleeding.
You might have bleeding and discharge for about 4 weeks after having a LLETZ. You shouldn’t use tampons or have sex during this time to reduce your risk of infection.
See your GP or contact your colposcopy nurse if you have:
- bleeding that is heavier than a period or you’re still bleeding after 4 weeks
- discharge that smells unpleasant
Precancerous conditions of the uterus
Atypical endometrial hyperplasia is a precancerous condition that can develop in the lining of the uterus (called the endometrium). It is an overgrowth of abnormal cells, or it can develop from endometrial hyperplasia, which is an overgrowth of normal cells. Sometimes polyps that grow in the uterus will have atypical endometrial hyperplasia.
Atypical endometrial hyperplasia is not yet cancer. But if it isn’t treated, there is a chance that these abnormal changes may become uterine cancer.
Atypical endometrial hyperplasia is usually seen in older women. It can also develop in younger women who do not ovulate or are obese.
Atypical endometrial hyperplasia develops when the female hormones, called estrogen and progesterone, are out of balance, and the endometrium is exposed to somewhat more estrogen than progesterone. This is called unopposed estrogen. Several things can cause this imbalance, including:
- hormone changes during menopause
- estrogen-only hormone replacement therapy (HRT)
- tamoxifen (Nolvadex, Tamofen) given to treat breast cancer
The most common symptom of atypical endometrial hyperplasia is abnormal vaginal bleeding. Some women may have abnormal vaginal discharge or an abnormal Pap test result, but these are less common.
If you have symptoms or your doctor thinks you might have atypical endometrial hyperplasia you will be sent for tests. Tests used to diagnose atypical endometrial hyperplasia may include the following.
Endometrial biopsy removes small pieces of the lining of the uterus (called the endometrium) so they can be looked at under a microscope. It is usually done in the doctor’s office.
Dilation and curettage (D&C) is a procedure in which the cervix (the lower, narrow part of the uterus, or womb) is widened (dilated) so that a curette (a spoon-shaped instrument with a sharp edge) can be inserted into the uterus to remove cells, tissues or growths from the endometrium (the inner lining of the uterus).
Treatment for atypical endometrial hyperplasia depends on:
- how different the abnormal cells are from normal cells
- the amount of bleeding
- surgical risks
- whether the woman might want to have children in the future
Treatment options for atypical endometrial hyperplasia may include:
- hysterectomy for post-menopausal women
- progesterone therapy for women who might want to have children in the future
Surgery for Cervical Cancer
Many women with cervical cancer will have some type of surgery. Surgery can be used to:
- Help diagnose cervical cancer
- Help determine how far the cancer has spread
- Help treat the cancer (especially for early-stage cancers)
Surgery for cervical pre-cancers
Two types of procedures can be used to treat pre-cancers of the cervix:
- Ablation destroys cervical tissue with cold temperatures or with a laser rather than removing it.
- Excisional surgery (conization) cuts out and removes the pre-cancer.
Cyrosurgery is a type of ablation where a very cold metal probe is placed directly on the cervix. This kills the abnormal cells by freezing them. It is used to treat cervical intraepithelial neoplasia (CIN). This can be done in a doctor’s office or clinic. After cryosurgery, you may have a watery brown discharge for a few weeks.
Laser ablation directs a focused laser beam through the vagina to vaporize (burn off) abnormal cells. This might be done in a doctor’s office under local anesthesia (numbing medicine) or in the operating room with general anesthesia since it can cause more discomfort than cryotherapy. It is also used to treat cervical intraepithelial neoplasia (CIN).
Another way to treat cervical intraepithelial neoplasia (CIN) is with excisional surgery called conization. The doctor removes a cone-shaped piece of tissue from the cervix. The tissue removed in the cone includes the transformation zone where cervical pre-cancers and cancers are most likely to start. A cone biopsy is not only used to diagnose pre-cancers and cancers. It can also be used as a treatment since it can sometimes completely remove pre-cancers and some very early cancers.
The procedure can be done in different ways:
- Using a surgical blade (cold knife cone biopsy)
- Using a laser beam (laser conization)
- Using a thin wire heated by electricity (the loop electrosurgical excision procedure, LEEP or LEETZ procedure).
Surgery for invasive cervical cancer
Procedures to treat invasive cervical cancer are:
- Hysterectomy (simple or radical)
A simple hysterectomy removes the uterus (both the body of the uterus and the cervix) but not the structures next to the uterus (parametria and uterosacral ligaments). The vagina and pelvic lymph nodes are not removed. The ovaries are usually left in place unless there is another reason to remove them.
Simple hysterectomy can be used to treat certain types of severe CIN or certain types of very early cervical cancer.
There are different ways to do a hysterectomy:
- Abdominal hysterectomy: The uterus is removed through a surgical incision in the front of the abdomen.
- Vaginal hysterectomy: The uterus is removed through the vagina.
- Laparoscopic hysterectomy: The uterus is removed using laparoscopy. First, a thin tube with a tiny video camera at the end (the laparoscope) is inserted into one or more very small surgical incisions made on the abdominal wall to see inside the abdomen and pelvis. Small instruments can be controlled through the tube(s), so the surgeon can cut around the uterus without making a large cut in the abdomen. The uterus is then removed through a cut in the vagina.
- Robotic-assisted surgery: In this approach, the laparoscopy is done with special tools attached to robotic arms that are controlled by the doctor to help perform precise surgery.
General anesthesia is used for all of these operations.
For a laparoscopic or vaginal hysterectomy, the hospital stay is usually 1 to 2 days, followed by a 2- to 3-week recovery period. A hospital stay of 3 to 5 days is common for an abdominal hysterectomy, and complete recovery takes about 4 to 6 weeks.
Possible side effects: Any type of hysterectomy results in infertility (inability to have children). Complications are unusual but could include bleeding, infection, or damage to the urinary or intestinal systems such as the bladder or colon.
Hysterectomy does not change a woman’s ability to feel sexual pleasure. A woman does not need a uterus or cervix to reach orgasm. The area around the clitoris and the lining of the vagina remain as sensitive as before a hysterectomy. More information about managing the sexual side effects of cervical cancer treatment can be found in Sex and the Woman with Cancer.
For this operation, the surgeon removes the uterus along with the tissues next to the uterus (the parametria and the uterosacral ligaments), the cervix, and the upper part (about 1 inch ) of the vagina next to the cervix. The ovaries are not removed unless there is some other medical reason to do so. More tissue is removed in a radical hysterectomy than in a simple one, so the hospital stay can be longer. Some lymph nodes will also be removed and checked for cancer at this time.
This surgery is usually done through a large abdominal incision (also known as open surgery). Often, some pelvic lymph nodes are removed as well. (This procedure, known as lymph node dissection, is discussed later in this section.)
A radical hysterectomy can also be done using laparoscopy or robot-assistance. (See the Simple hysterectomy section for a description of laparoscopy.) These techniques are also referred to as minimally invasive surgery. Laparoscopic (or robotic) surgery can result in less pain, less blood loss during the operation, and a shorter hospital stay compared to open surgery. However, it is very important to note that recent studies have shown that women who have minimally invasive radical hysterectomies for cervical cancer have a higher chance of the cancer recurring and a higher risk of dying from the cancer than those who have surgery through an abdominal incision (open surgery). Having a radical hysterectomy through an abdominal cut is the preferred type of surgery in most cases. Laparoscopic surgery may still be an option for a small specific group of women with early stage cancer, but you should discuss your options carefully with your doctor.
A modified radical hysterectomy is similar to a radical hysterectomy but does not remove as much of the vagina and tissues next to the uterus (the parametria and the uterosacral ligaments) and lymph nodes are usually not removed.
Possible side effects: Because the uterus is removed, this surgery results in infertility. Because some of the nerves to the bladder are removed, some women have problems emptying their bladder after this operation and may need a catheter for a time. Complications are unusual but could include bleeding, infection, or damage to the urinary and intestinal systems such as the bladder or colon.
Removal of some of the lymph nodes to check for cancer may sometimes result in lymphedema (leg swelling). This is not common, but may happen after surgery and treated with different methods.
Radical hysterectomy does not change a woman’s ability to feel sexual pleasure. Although the vagina is shortened, the area around the clitoris and the lining of the vagina is as sensitive as before. A woman does not need a uterus or cervix to reach orgasm. When cancer has caused pain or bleeding with intercourse, the hysterectomy may actually improve a woman’s sex life by stopping these symptoms. More information about managing the sexual side effects of cervical cancer treatment can be found in Sex and the Woman with Cancer.
A radical trachelectomy, allows women to be treated without losing their ability to have children. The operation is done either through the vagina or the abdomen, and is sometimes done using laparoscopy.
This procedure removes the cervix and the upper part of the vagina but not the body of the uterus. The surgeon then places a permanent “purse-string” stitch inside the uterine cavity to keep the opening of the uterus closed, the way the cervix normally would.
Diagnosing Endometrial Cancer
Doctors at NYU Langone are experienced in diagnosing endometrial cancer. This cancer begins in the endometrium, the lining of a woman’s uterus—the pear-shaped organ in which a baby develops during pregnancy. Endometrial cancer is the most common type of cancer affecting a woman’s reproductive system.
Most women with endometrial cancer experience some kind of abnormal vaginal bleeding: bleeding between menstrual periods, unusually heavy menstrual periods, or bleeding after menopause. Some women experience other symptoms, such as pelvic pain or pain during intercourse or urination.
Endometrial cancer occurs most often in women between the ages of 50 and 60. Nearly half of women who are diagnosed with this cancer have obesity, meaning they have a body mass index—a ratio of weight and height—of 30 or higher.
Fat cells produce excess estrogen, a hormone that increases the risk of endometrial cancer. Women with obesity may have up to four times the risk of developing endometrial cancer than women of normal weight. Endometrial cancer is also more common in women who have conditions associated with obesity, such as type 2 diabetes and polycystic ovarian syndrome.
Women who began menstruating before age 12 and stopped having menstrual cycles relatively late in life have a higher risk of developing endometrial cancer. This is because they have been exposed to estrogen for a longer period of time. Women who have never been pregnant, and haven’t experienced the temporarily lower estrogen levels associated with pregnancy, are at higher risk.
Other conditions that raise the risk of developing this type of cancer are endometrial polyps, noncancerous growths such as cysts, and endometrial hyperplasia, which is a thickening of the endometrium that may be precancerous.
Women who take the medication tamoxifen for the prevention or treatment of breast cancer and those who use estrogen replacement therapy to ease symptoms of menopause may also have a higher risk of developing endometrial cancer.
However, women who have taken combination oral contraceptives, or birth control pills, that contain the hormones estrogen and progestin, may have a lower risk. This is because progestin combats estrogen-fueled cell growth and protects the lining of the uterus. This protective effect increases with the length of time you use these contraceptives and continues for many years after you stop taking birth control pills.
The risk of endometrial cancer is higher in women who have Lynch syndrome, which is caused by several gene mutations that increase the risk of many cancers, including colorectal and ovarian cancer.
NYU Langone doctors use several tests to diagnose endometrial cancer or to look for precancerous cells, which are cells that have undergone changes that often precede cancer development.
Having a yearly pelvic exam may alert your doctor to symptoms, such as unusual vaginal bleeding, that may warrant diagnostic testing.
During a pelvic exam, your gynecologist may perform a screening test, also known as a Pap test, for cervical cancer. In this test, the doctor uses a small brush to gently scrape cells from the vagina and cervix, which is the bottom portion of the uterus.
A pathologist, a doctor who looks at tissue samples to identify abnormalities, examines the cells under a microscope to look for any precancerous or cancerous changes. Although this test is not performed to screen for endometrial cancer, it may indicate the presence of abnormal endometrial cells, prompting additional testing.
Your NYU Langone doctor may perform an endometrial biopsy if you have abnormal bleeding or if your Pap test reveals precancerous endometrial cells.
In this test, the doctor inserts a very thin, flexible tube called a catheter through the vagina and into the uterus. A small amount of the endometrium is suctioned out and later examined by a pathologist to look for precancerous or cancerous cells.
The procedure is performed in the doctor’s office using local anesthesia. It can be completed in fewer than 10 minutes.
Endometrial biopsy results are often very informative. However, because the biopsy samples are taken from a random place in the uterus, they occasionally fail to detect precancerous or cancerous growths.
In some instances, fibroids—noncancerous growths in the wall of the uterus—may obstruct the entrance to the uterus, preventing the doctor from obtaining an adequate biopsy sample.
If your symptoms persist and the results of an endometrial biopsy do not reveal any precancerous or cancerous cells, your doctor may perform a transvaginal ultrasound. This test uses sound waves to create computerized images of the uterus, ovaries, and fallopian tubes.
Transvaginal ultrasound allows your doctor to look for signs of endometrial hyperplasia, a thickening of the lining of the uterus that can lead to cancer. It may also be performed when you have had an abnormal Pap test result, abnormal bleeding, or other symptoms.
In this test, conducted at the doctor’s office, a wand called a transducer is inserted into the vagina to create an image that allows the doctor to measure the thickness of the endometrium.
Hysteroscopy with Dilatation and Curettage
Your doctor may perform a hysteroscopy with dilatation and curettage if the results of an endometrial biopsy are inconclusive or the doctor couldn’t obtain enough tissue for a biopsy.
In this procedure, the doctor widens the opening of the cervix with thin, metal rods called dilators. Then, he or she inserts a hysteroscope—a thin tube with a tiny camera on the end—into the uterus through the cervix. This allows the doctor to view the uterus for growths or signs of endometrial hyperplasia and to determine which area of the uterus to remove for a biopsy.
The doctor then inserts an instrument called a curette to remove a small amount of endometrial tissue for examination under a microscope. Different instruments may be used to remove endometrial tissue, as needed.
A pathologist who specializes in detecting changes in uterine tissue can determine if your endometrium contains precancerous or cancerous tissue. If the endometrium contains growths, the pathologist can determine if cancer is present.
If the growth is cancerous, the pathologist identifies the tumor’s risk of growing and spreading. This information, along with details about the tumor’s size and how much it may have invaded the uterine muscle wall, is used to determine the cancer’s risk of spreading.
Hysteroscopy with dilatation and curettage is a minor surgical procedure performed in the hospital at NYU Langone. It usually lasts less than 30 minutes, and requires either epidural anesthesia, which blocks pain below the waist, or general anesthesia. Most women return home the same day.
Additional Imaging Tests
If a biopsy confirms that you have endometrial cancer, imaging tests may be performed to determine the size of the tumor and if the cancer has spread. Doctors may recommend a CT scan, a type of X-ray that uses a computer to create cross-sectional, three-dimensional pictures of the uterus. They may also suggest an MRI scan, which uses a magnetic field and radio waves to create computerized, three-dimensional images of soft structures in the body.
Before a CT or MRI scan, a contrast agent or dye that enhances the image may be injected into a vein or given to you by mouth.