Monday 11^th June marks the beginning of Cervical Screening Awareness Week 2018. To start with I’ll just run through a bit about cervical screening…

• It used to be called the ‘smear test’
• It’s a screening test to look for abnormal pre-cancerous cells on the cervix
• The cervix is the neck of the womb (the opening between the vagina and the womb/uterus)
• It takes about 5 minutes to perform
• only 5% tests will be abnormal
• 25-49yr olds will be offered the test every 3 years, 50-64yr olds every 5 years
• Women over 65 may be screened if they haven’t recently been tested or have recently had an abnormal test

I will say this early on in case you get bored and don’t read all the way down. If you are due or have missed your last screening, please do book in – it really does save lives.

Why don’t all eligible women attend?

Here are some of the reasons I hear every day and I hope I can allay some fears with this post:

• I’m worried it’ll hurt too much
• I had a bad experience once where it was sore and I don’t want to go through that again
• They can never find my cervix, what’s the point?
• It’s so embarrassing
• I don’t like intimate examinations, it makes me uncomfortable
• I haven’t tidied up down there..i need to trim/shave etc etc
• I forgot when my last one was and threw away the letter

What is a screening test?

My old lecturer Dr Oliver will go nuts if I get this bit wrong!

A screening test is a test that is done on asymptomatic individuals, i.e. they have no clinical symptoms. The test should pick up any abnormalities prior to that person developing symptoms of a specific condition or group of conditions. Screening is offered to the cohort of people that will benefit most from it, hence why cervical screening is only offered to certain age groups…and individuals with a cervix. If a screening test is positive, we then perform diagnostic tests to see what your condition might be.

What happens when we perform cervical screening?

In general, you will see a nurse at your GP practice for your cervical screening test. I think ‘smear test’ gives it a negative connotation. Years ago it was called a smear as the sample that was collected was ‘smeared’ on to a lab slide. You will initially sit down and the nurse will explain the process of the test and how you will receive your results. The nurse will try to put you at ease and reassure you as much as possible.

I’m 33 and had three cycles of screening, thankfully all normal; I can tell you what it’s like as a patient and as a clinician performing the test. It shouldn’t be painful but may be slightly uncomfortable. I am always a bit anxious before going in as two of my three sisters have needed treatment for abnormal cells and it’s not something in general one looks forward to! I have to say the procedures have always been quick and painless.

The hardest part, for me, was booking the appointment, finding a nurse appointment that suited my work schedule was hard! This is something practices really need to work on. Uptake of the screening is falling (the Jade Goody effect is fading) so we need to make it as simple as we can for women to book appointments. We should be offering evening and weekend clinics if at all possible. If I, as a GP, struggled to navigate the process then it shows how challenging it can be for someone with limited medical knowledge.

You may be offered a chaperone and do take this up if you would like someone else in the room.

Here is the typical process:

• Go behind the curtain and undress from the waist down, there should be something to cover yourself with, maybe just a large piece of tissue paper but it’s better than nothing if you’re feeling self conscious
• The nurse will get the equipment required out: a speculum (that plastic thing that looks more scary than it is), some lubricating jelly, the brush to take the specimen and a sample pot to put the brush in when finished

• The speculum opens up the vagina so we can see you cervix clearly. Your cervix looks like a circle with a small hole in the middle

• You may not be aware but there are different sizes of specula!

• If you have a cervix that likes to hide there are some simple techniques your nurse may use to make it more visible, e.g. putting your hands under your bottom or coughing
• The nurse will then insert a small brush, it looks a little bit like a swab with soft bristles, that gets turned a few times and then you’re done!

• You will be informed how long results in the post may take, currently this is 2-6 weeks.
• Some women bleed afterwards, usually light spotting.

 

The ideal time to have your test is ‘mid-cycle’ ie around day 14 of a 28 day cycle, day 1 is the first day of your period.

It really is quick and simple in most cases…please do book in if you’re overdue.

So what do the results mean?

To keep us ladies and clinicians on our toes, NHS England are changing the way that samples are tested from 2019…To keep it simple I’ll explain the current system and then the updated version afterwards!

The sample is looked at under a microscope in a cytology lab. The result could be reported as ‘normal’ and you will go back to ‘routine recall’, i.e be invited by post to have your next test in 3-5 years depending on age.

An ‘inadequate’ result means not enough of a sample was taken or something has interfered with the processing. You might be asked to repeat the test in three months time.

If it is abnormal, these are the results you might see:

• Borderline or low grade dyskaryosis
  • If you have either of these then the lab will then test your sample for HPV, this is human papilloma virus
  • HPV is a group of viruses (there are over 100 of them) that can cause genital infections and lead to cervical cancer
  • If you are HPV positive you will be referred for a colposcopy (see below)
  • If you are HPV negative you will be invited back to your routine recall and no further tests are needed

• Moderate or severe dyskaryosis
  • You will be invited to have a colposcopy (see below)

Dyskaryosis means abnormal cell changes, these may be pre-cancerous but it doesn’t mean that you have cancer.

From 2019, the samples will be tested for HPV before they are tested under the microscope for abnormal looking cells. This is because the HPV test is supposed to be better at showing whether someone is at risk of cervical cancer.

What if i have abnormal cells and am referred?

To start with you will be offered a colposcopy which is a test usually done at the gynaecology clinic. It is like a large microscope, which allows the clinician to look at you cervix in more detail. Dyes can be added to the cervix to highlight any abnormal changes. A biopsy (a small sample) can be taken to get more information. You will be sent some written information about this if you have been referred after a screening test.

If the results suggest you need treatment for the abnormal cells, to prevent them turning cancerous, a loop excision (done in the clinic setting) or a cone biopsy (generally done under general anaesthetic) will be advised. I will add some links to more information about these below.

When is screening not appropriate?

It should only be used if you don’t have symptoms. If you are worried you have symptoms that may suggest you have cervical cancer then it is best to see your GP to discuss this and arrange an examination. These symptoms may include: bleeding in between your period, bleeding after sex or abnormal discharge. When we examine your cervix (again with a speculum) we can see whether it looks normal or not, if it looks abnormal then we can refer you to gynaecology for them to decide on the next tests.

What else can we do to prevent cervical cancer?

There are over 3100 new cases of cervical cancer each year in the UK. Cervical screening aims to reduce this but the vaccination against HPV may prove to be a better way to prevent it.

The vaccine is offered to girls over the age of 12, it requires two doses, the first given when they are in year 8 and the second 6-12 months later. Gardisil, the vaccine brand used, protects against HPV 6, 11, 16 and 18. More than 70% of cervical cancers are caused by HPV 16 and 18, and types 6 and 11 cause most cases of genital warts. It was introduced in 2008 so the 12/13yr old girls will now be coming up to 23yrs old and not yet entered the cervical screening program. It will be interesting to see how much the vaccination program has affected the numbers of abnormal screening results in the coming years.

HPV is known to be associated with other genital cancers (vulval, anal and penile) and there is an argument to vaccinate boys as well as girls. Currently teenage boys are not on the vaccination schedule but can decide to pay for it if they or their parents feel it may be in their best interest long term.

I wonder if I personally will opt to get my little man vaccinated when he reaches the appropriate age. A lot of doctor colleagues would say it’s a ‘no brainer’ – not only protecting the boy from future cancers but also helping to reduce HPV transmission in those women that haven’t been vaccinated or have not entered in to the cervical screening program.

 

On a different note, there is a move to offer self taken tests for screening of HPV to improve uptake and reduce cervical cancer rates. These are currently available privately but it is an area of potential research and change in the coming years.

 

This is the last time I will say it….please do get booked in if you are due or overdue. Let’s reduce the number of ladies suffering with cervical cancer and prevent more deaths from the disease.

If you are worried about the process then please do book in with your GP to have an honest conversation about what it involves and any worries you may have. The thought of the test is probably much worse than the actual procedure itself!

 

Some useful websites:

• Cervical screening – Cancer Research UK
• Cervical cancer – Eve Appeal
• Colposcopy – NHS Choices
• HPV – NHS England
• Treatment of abnormal cells – Jo’s Trust (a charity dedicated to cervical abnormalities and cancer)