Frequently Asked Questions
Frequently Asked Questions
Get reliable answers to common questions about HPV, cervical cancer, screening, and treatment. For concerns not covered here, please consult a healthcare professional. Early detection and regular screening are key to prevention.
Understanding HPV and Cervical Cancer
Prevention and Risk Reduction
HPV, also known as Human Papilloma Virus, is a DNA virus which can be transmitted via direct contact, including sexual activity. There are over 100 subtypes of HPV virus, of which 14 subtypes are considered “high-risk” and related to cancer. HPV Type 16 and 18 account for 70% of HPV-associated cancers. HPV-associated cancers also include cervical, anal, vulvar, and throat cancer.
HPV may be transmitted via any form of direct skin-to-skin contact, and is not transmitted solely via sexual intercourse. It is not exclusively a sexually transmitted infection and may be found in women who have not been sexually active for a very long or are in stable monogamous relationships.
About 99% of cervical cancer are caused by HPV infection. Most of the time, HPV infections of the cervix are cleared on their own and it does not develop into cervical cancer. However, in some women, it can remain persistent and subsequently lead to cervical cancer. Prior to turning into cancer, this would progress through several precancerous stages (refer to FAQ on What is CIN and HSIL?). If these are detected early, the progress can be halted and cured through relatively simple procedures. This is why cervical cancer screening is very important.
CIN stands for Cervical Intraepithelial Neoplasia and refers to pre-cancerous conditions of the cervix. There are 3 levels of CIN; CIN 1, 2 and 3. The higher the level of CIN, the higher the severity of abnormality.
LSIL and HSIL, or Low- and High-grade Intraepithelial Lesion respectively, belong to a different classification system. LSIL equates to CIN 1 and often requires just monitoring as the majority of cases resolve on their own. HSIL equates to CIN 2 and CIN 3 and may require treatment to prevent progression to cancer.
HPV infection can be prevented primarily by obtaining the HPV vaccine, especially in young persons who are not yet sexually active. HPV vaccines are given in 2-3 divided doses, depending on the recipient’s age. Barrier contraception, such as condoms, may partially reduce the chance of HPV infection. However, as HPV can be transmitted via skin-to-skin contact, there is a risk of transmitting HPV to areas not covered by the condom.
Maintaining a healthy lifestyle to boost immunity may contribute to the ability to combat HPV infections. Smoking reduces the body’s ability to clear HPV infections and is a major risk factor for cervical cancer.
Your risk of developing cervical cancer depends on the presence of high-risk HPV infection in your cervix or the presence of abnormal cells representing pre-cancerous changes of the cervix. These can be determined via a pap smear or a HPV test of the cervix.
The HPV vaccine has maximal benefit in women who are under the age of 26 and are not yet sexually active. However, it still has good benefits for women up to the age of 45 even if they have ever been sexually active or have had HPV infections. This is because multivalent HPV vaccines (i.e. covers several HPV subtypes) would prevent future infections from other high-risk HPV subtypes. HPV vaccination has also been found to be particularly beneficial in women who have been treated for HPV-associated conditions of the cervix.
Out of a large number of HPV subtypes, about 14 are known to be cancer causing. Of these, Types 16 and 18 are responsible for the largest proportion of cervical cancer. All cervical cancer vaccinations cover Types 16 and 18. While older vaccines cover a narrower range of HPV subtypes, the latest vaccine (Gardasil-9®) cover for 7 cancer causing types. None of the available HPV vaccines cover for every type of high-risk HPV. Other possibilities include that this HPV infection may have persisted from before you received the HPV vaccine or that, as with any vaccine, you may be one of a small proportion of recipients who may not develop immunity after receiving this vaccine.
Screening and Diagnosis
A pap smear or HPV tests are two different tests that are can be used to assess for the risk of cervical cancer. They are simple clinic-based procedures. First, your Doctor or Nurse will insert a device (speculum) into your vaginal canal to visualise your cervix. Next, a soft brush will be used collect a sample from your cervix. The sample will be sent either for examination under a microscope (pap smear) or to detect HPV DNA.
There is currently no specific approved HPV test for your male partner. However, if your partner has symptoms of HPV infection, such as genital warts, he should see his healthcare provider for further evaluation and treatment.
There is also a growing consensus that men should also receive the HPV vaccine as part of a strategy of developing herd immunity in order to reduce transmission to women and reduce HPV-related cancers in men.
Women who need closer monitoring include;
- Women with reduced immunity e.g. on immunosuppressive drugs, have autoimmune conditions, are organ transplant recipients, are those living with HIV
- Previous abnormal results, especially high-grade pre-cancerous conditions
- Women with previous treatment for cervical abnormalities
- Women with persistent HPV infections
Cervical cancer screening is not recommended for women who have never been sexually-active as the risk of a HPV infection is very low and a speculum examination may be very uncomfortable. Nevertheless, if you have abnormal vaginal bleeding, please seek medical attention early. Sex toys and other forms of non-penile intercourse may put one at risk of HPV infections, and thus, cervical cancer.
A colposcopy is a detailed examination of the cervix using a device called a colposcope which like a “magnifying glass”. This is performed by an accredited colposcopist (i.e. a gynaecologist who has met the standards of SCCPS for performing this procedure).
During this procedure, some chemicals such as acetic acid (which is the primary component in vinegar) and liquid iodine will be applied to the cervix to identify abnormal areas based on colour changes. This may cause some temporary sting especially in older women.
While a colposcopist will give you an immediate visual assessment of the cervix, small tissue samples (i.e. biopsies) may be needed to confirm what is going on at a microscopic level to plan your future care.
A colposcopic examination entails a speculum examination just like the cervical cancer screen you many have undergone. Some discomfort may be felt at the entrance during the insertion of the speculum. There may be stinging or smarting when applying acetic acid and iodine. A dull lower abdominal ache may be felt at the time of biopsy. Most women do not feel much pain and, if at all, this would be temporary.
Thus, a colposcopy does not usually require numbing. However, please share your concerns about pain and sensitivity in the intimate regions with your colposcopist prior to the procedure. They will advise you accordingly and will aim to further reduce your discomfort.
Treatment and Follow-Up Care
A positive HPV test does not necessarily mean you have cervical cancer. Further evaluation is needed to ensure you do not have a pre-cancerous condition or, rarely, cervical cancer. Follow-up is required until the HPV infection is cleared. In the event that any pre-cancer is detected during this surveillance, it should be treated.
Most HPV infections get cleared by your immune system. If you are tested positive for HPV, your healthcare provider may recommend the following;
- undergoing colposcopic assessment or repeating the test again
- attending regular screening
- maintaining a healthy lifestyle to keep your immune system healthy
- stopping smoking
Unfortunately, at present, there are no medications available to aid in clearing a HPV infection.
This depends on your age, fertility goals as well as the location and severity of your precancerous lesion.
Low-grade Intraepithelial Lesions (LSIL) are typically monitored with repeated colposcopic examinations and/or pap smears.
High-grade Intraepithelial Lesions (HSIL) are usually treated by ablation (i.e. using energy – see more details below) or excision (i.e. removing the area of concern – see more details below). Younger women with fertility plans may be offered surveillance on a case-by-case basis. However, close follow-up is needed.
Treatment may involve one of the following approaches
a) Ablation
This either involves a laser beam (laser vaporisation) or heat (cold coagulation or thermal ablation) to burn away unhealthy cells while causing little to no damage to the surrounding healthy tissues. While this preserves the strength of the cervix, no tissue can be sent to the laboratory for examination and is limited only to directly visible unhealthy cervical tissue. This approach may not be suitable for certain patients, especially where the area of concern is deeper and not easily accessible or where tissue analysis is needed. These procedures can be done either in clinic or under general anaesthesia as a day procedure.
b) Excision
This involves removal of the part of the cervix which is abnormal and most likely to harbour precancerous tissue. This includes areas that are not easily seen on a colposcopy. There are two kinds of procedures i.e.
Loop Electrosurgical Excision Procedure (LEEP) / Large Loop Excision of the Transformation Zone (LLETZ )
A heated thin wire loop electrode is used to remove a layer of cervix. This procedure is typically done in clinic and is well tolerated with local anaesthesia. It may also be done as a day procedure under general anaesthesia.
Cervical cone biopsy
A heated needle or a laser beam is used like a knife to remove a cone of cervix to obtain a deeper tissue sample while being able to trace out the area of concern with better precision. This is usually done under general anaesthesia as a day procedure.
The following are potential risks and complications of the surgery (non-exhaustive):
a) Bleeding
Medication is applied on the cervix to reduce bleeding. Heavy bleeding may occur one to two weeks after the procedure. Medication may be prescribed orally and applied directly to the wound to stop the bleeding. Gauze may be inserted into the vagina to provide pressure to reduce the bleeding and, rarely, stitches may be required. You are advised to seek medical treatment immediately if you experience heavy bleeding.
b) Infection
Infections at the cervix may occur after the surgery. Antibiotics may be prescribed after cervical procedures to reduce this risk. While most infections can be easily treated with antibiotics, in rare cases it may be life-threatening.
c) Prolonged vaginal discharge
Prolonged vaginal discharge is common and can sometimes last for 4-6 weeks after surgery. This is usually not due to an infection but is part of the normal healing process of the cervix. However, if the discharge is thick, foul smelling, contains pus, or there is associated pain or associated with a fever, you may have an infection (refer to 15b above).
d) Injury to neighbouring organs
The cervix is located close to the vaginal wall, bladder, and rectum. Thus, injury to these organs is rare, but possible. This risk is higher in postmenopausal women with smaller cervices and thinner vaginal walls. Bladder injury may present as persistent clear vaginal discharge. Depending on the extent of injury, further surgery may be required.
e). Cervical stenosis (narrowing of the cervix) or incompetence (weakness of cervical muscles)
Surgery on the cervix may result in fibrosis (i.e. scarring) or incompetence of the cervix. Scarring of the cervix may cause obstruction of menstrual flow and pelvic pain, which may require further intervention.
Cervical incompetence may result in an increased risk of miscarriages or preterm deliveries. While this is mainly seen with excisional treatments of the cervix, the actual risk is relative low and steps can be taken during pregnancy to reduce this risk further. Consult your gynaecologist early if you become pregnant and inform them that you had undergone a cervical procedure.
A hysterectomy is rarely needed for precancerous lesions. This is usually recommended for patients with invasive cancer, severe recurring abnormalities, or certain uncommon cervical abnormalities (e.g. adenocarcinoma-in-situ).
The decision for a hysterectomy depends on individual circumstances and should be discussed with your SCCPS-accredited colposcopist.
This depends on the type of abnormality involved and the treatment received. Follow-up is needed until HPV clearance or, if treatment is performed, for at least two year after. If these tests are negative, you may return to routine screening. You will be ably advised by your SCCPS-accredited colposcopist.