Reproductive and Sexual Health Handbook

The cervix is the lower part of the uterus. In a non-pregnant woman it is typically 2.5cm long and forms a narrow canal, which separates the upper genital tract from the lower genital tract. The proximal end of this canal communicates with the uterus via the internal os, and the distal end opens into the vagina at the external os. The external os may appear as a tight circular aperture in nulliparous women, and more of a transverse slit following childbirth.⁽¹⁾

The cervix can be divided into 2 parts: (see Figure 2.1)

The Endocervix – the inner part of the cervical canal, lined with columnar epithelium. The Ectocervix – the more distal part of the cervix that protrudes into the vagina and is covered by non-keratinised stratified squamous epithelium.

Between these two parts is the squamocolumnar junction or transformation zone, where there is progression of epithelial cells undergoing metaplastic change. It is in this zone where squamous cell carcinoma of the cervix tends to arise.⁽²⁾

Figure 2.1 The Ectocervix and Endocervix

Reproduced by permission of Jo’s Cervical Cancer Trust. The Cervix [Internet]. Updated 2016 Oct 20. Available from: https://www.jostrust.org.uk/information/cervix/about-the-cervix

When viewed through a vaginal speculum the healthy cervix appears smooth and pink. The transformation zone may not be visible, especially in postmenopausal patients, and may be difficult or even impossible to sample. This is not thought to compromise a cervical screening test result, however ⁽³⁾ (see Figure 2.2).

A variation of this appearance is that of cervical ectropion (also called cervical ectopy) which in the past was often referred to as cervical erosion. This occurs when the transformation zone is visible on the ectocervix (see Figure 2.2 and Figure 2.3). It is seen when the columnar epithelium migrates onto the vaginal portion of the cervix due to hormonal changes.

A cervical ectropion can appear red and may look inflamed because the single layer of columnar epithelium makes the underlying blood vessels more apparent compared to the multiple layered squamous epithelium. The columnar epithelium may also secrete more mucus than the vaginal mucosa and may cause a physiological vaginal discharge. This is a normal finding in high-oestrogen states, such as in a young person, during pregnancy, or in patients using oestrogen therapy, including the combined oral contraceptive pill (see Figure 2.2).

‘Contact bleeding’ is common with a

The columnar epithelium of the endocervical canal, which can extend onto the cervix, contains glands which secrete mucus.⁽⁵⁾ Nabothian follicles (or cysts) are retention cysts on the cervix formed by the blockage of these glands due to the growth of new epithelium over a maturing cervical ectropion. They are often seen when taking a cervical sample. Nabothian cysts are cream in colour, smooth and dome shaped, and may be single or multiple. They are benign and do not require further management.

A useful resource for clinicians is VCS Pathology: National Cervical Screening Program Guidelines Cervix sampling card which shows various cervical conditions in full colour.

Worldwide, cervical cancer is the fourth most frequent cancer in women, with an estimated 570,000 new cases in 2018. It is estimated there will be approximately 311,000 deaths from cervical cancer every year, with more than 85 per cent of these occurring in less developed regions.⁽⁸⁾⁽⁹⁾

In Australia, cervical cancer was the 14th most commonly diagnosed cancer among females in 2014. It accounts for less than 2 per cent of all female cancers with a relatively low incidence of 7 new cases per 100,000 women of all ages. In 2015, there were 857 new cases of cervical cancer, with an age standardised rate of 9.6 per 100,000 women.⁽¹⁰⁾

In 2017, there were 230 deaths from cervical cancer (age standardised rate of 1.6 deaths per 100,000 women). ⁽¹⁰⁾ Both incidence and mortality halved between the introduction of the National Cervical Screening Program in 1991 and the year 2002, and have since remained at 9–10 new cases and two deaths per 100,000 women. ⁽¹⁰⁾ However some groups remain under-screened, and in Australia, 72% of invasive cervical cancers diagnosed between 2002 and 2012 were diagnosed in those who were either under-screened

Inflammation of the cervix, or cervicitis, may be responsible for post coital or intermenstrual bleeding. Depending on the cause of the inflammation there may be other associated symptoms such as vaginal discharge, pain with intercourse or a change in the odour of vaginal secretions.

The main cause of cervicitis in sexually active people is a sexually transmissible infection (STI). The most common STI causing cervicitis is Chlamydia trachomatis or, less often, Neisseria gonorrhoea.⁽⁵⁾ Mycoplasma genitalium, Trichomonas vaginalis and genital herpes are other possible causes (also see Chapter 12: Sexually Transmissible Infections (STIs) and Blood Borne Viruses). In people with a low risk of STIs, cervicitis is often not associated with an identifiable pathogen ⁽⁵⁾(see Sexually Transmissible Infections in Chapter 4: The Vagina and Vulva).

KEY POINT

Check for Chlamydia in all cases of post coital or intermenstrual bleeding.

Figure 2.2 Transformation zone of the cervix

Reproduced by permission of CancerCare Manitoba, CervixCheck. The Pap test learning module for healthcare providers [Internet]. Manitoba, CervixCheck; 2009 June [Updated 2019 March; cited 2019 April 10]. Available from: https://www.cancercare.mb.ca/export/sites/default/screening/.galleries/files/screening-files/x-ptlm.pdf

Cervical polyps are a common and often incidental finding at the time of routine cervical screening occurring in up to 10 per cent of patients.⁽⁶⁾ Most cervical polyps are asymptomatic, especially in postmenopausal patients, however approximately one third are associated with abnormal vaginal bleeding including intermenstrual, irregular or post coital bleeding.

Cervical polyps are polypoid growths which originate at the ectocervix or the endocervix and are between 5mm and 5 cm in size. Endocervical polyps are most prevalent in patients aged 40 to 65 years.⁽⁶⁾ They are usually cherry red in appearance, single or multiple, and may appear as a pedunculated lesion on a stalk. Ectocervical polyps are usually single greyish-white smooth lesions. They are associated with a very low risk of malignancy (0-0.1 per cent) but this risk increases with age.⁽⁶⁾ Differential diagnoses for cervical polyps include a prolapsed endometrial polyp or fibroid as well as malignancy.

Older patients are also more likely to have associated endometrial polyps which can be visualised on a pelvic ultrasound and are associated with a higher risk of malignancy.

Management of cervical polyps

Management of cervical polyps will depend on a number of factors including the patient’s age, size

Development of vaccines to prevent oncogenic HPV infections means that for the first time there is a potential primary prevention tool against cervical and other HPV-related cancers.

There are two HPV vaccines currently available in Australia:

The nonavalent vaccine (Gardasil 9) protects against nine HPV types: 6, 11, 16, 18, 31, 33, 45, 52 and 58. It was introduced into Australia in 2018. The overall protection against cervical cancer is estimated at 89 per cent globally.⁽²⁸⁾ The bivalent vaccine (Cervarix) protects against HPV 16 and 18.

The quadrivalent HPV vaccine for HPV types 6, 11, 16 and 18 is no longer available in Australia.

KEY POINT – Cervical screening if vaccinated

Vaccination is not an alternative to cervical screening as HPV types other than those within the vaccine have the potential to cause cervical cancer. For women who have ever been sexually active regular cervical screening remains an important preventative measure against cervical disease.

 

KEY POINT – Gardasil 9

The 9vHPV vaccine shows 97.4 per cent efficacy against cervical, vulval and vaginal neoplasias associated with HPV types 31,33,45,52 and 58. ⁽¹⁹⁾

HPV vaccines are recombinant protein particulate vaccines and predominantly provide antibody-mediated protection. It is therefore preferable to administer them prior to first sexual intercourse before potential exposure to sexually transmitted HPV as they have no effect on existing HPV infection.

KEY POINT

HPV vaccination does NOT:

treat existing HPV infection prevent disease caused by an existing vaccine HPV type infection ⁽¹⁹⁾

Australia launched the world’s first government-funded HPV vaccination program as a primary prevention against cervical cancer in 2007.⁽²⁹⁾ The National Immunisation Program initially funded a school-based program for females aged 12-13 years (with a two-year catch-up program for girls aged 13-26 years). In 2013 the program was extended to include vaccination of males aged 12-13 years (with a catch-up program for 14-15 year old boys until December 2014).⁽⁵³⁾

From 2007-2017 Australia’s National Immunisation program used the quadrivalent HPV vaccine (Gardasil). This was replaced in 2018 by the nonavalent HPV vaccine (Gardasil 9).

From 6 Feb 2023, the routine two dose schedule for Gardasil 9 given to those age 12-23 years changed to a single dose. Along with this change, the catch-up program for all young people was increased to 25 years of age.⁽⁵³⁾

Population-based screening for cervical cancer is recognised as an effective strategy to identify asymptomatic individuals who have a previously unrecognised disease. Cervical screening has seen dramatic reductions in the incidence of squamous cell carcinoma in Australia. Squamous cell carcinoma accounts for approximately 68% of all cervical cancers in Australia while glandular (adenocarcinomas) or mixed cancers accounted for approximately 24% of cases. ⁽¹⁰⁾

Australia has one of the lowest incidences of cervical cancer in the world. This is largely attributed to the successful implementation of the National Cervical Screening Program in 1991 which led to a 50% decrease in cervical cancer mortality in 10 years. ⁽³⁵⁾ Between 2002 and 2012, 72% of cervical cancer diagnoses in women aged 20-69 occurred in people who had never been screened or were lapsed screeners.⁽⁴⁴⁾

The overall age standardised screening participation rate for people aged 20-69 years (the previous target group for screening) was just under 56% in 2018-2020.⁽⁴⁴⁾

There are still groups who are under-screened, including those from lower socioeconomic groups and from culturally and linguistically diverse backgrounds. Available evidence also suggests Aboriginal and Torres Strait Islander women are an under-screened group with more than twice the

Despite the impressive success of the initial National Cervical Screening Program, incidence and mortality rates from cervical cancer have plateaued since 2002.⁽¹⁷⁾

In April 2014, the Australian Government announced changes to the NCSP, which came into effect from December 1st 2017 – referred to as “the renewal”. The renewal was based on extensive modelling studies and aimed to be a more effective, evidence-based screening program built on new knowledge about the role of HPV and the natural history of cervical cancer. At this time, the primary cervical screening test changed from two-yearly papanicolaou smear tests (cytology) to five-yearly cervical screening tests, which tested for human papilloma virus, with reflex liquid-based cytology (LBC) for those with a positive HPV test. Other recommendations from this time included:⁽¹⁷⁾

Cervical screening was recommended for all women and people with a cervix who had ever been sexually active, from the age of 25. At this time, cervical screening test still required a speculum examination to visualise the cervix so that a cell sample could be collected from the transformation zone. The option of self-collected HPV testing was introduced for a limited group of people: those aged over 30 years who were under-screened (two

HPV testing within the NCSP includes partial genotyping for HPV types 16 and 18, as these types are managed differently to other oncogenic HPV types (not 16/18) in the program. Compared with other oncogenic HPV types, HPV types 16 and 18 are associated with cervical abnormalities that are less likely to regress and more likely to progress to high grade lesions and cervical cancer. Identification of HPV 16 and 18 with partial genotyping improves risk stratification for women in the cervical screening program. ⁽¹⁷⁾

The renewed National Cervical Screening Program recommends all women who have ever been sexually active to commence screening at 25 years of age with a Cervical Screening Test. The screening interval is five years in asymptomatic women and those with a negative screening history or no history suggestive of cancer.

The laboratory report for cervical screening will show:

an overall risk assessment (low, intermediate or higher); a statement of the test(s) performed and results; and a recommendation for follow up/action, taking into account the clinical history.⁽¹⁷⁾

Figure 2.5 Cervical screening pathway (1st Feb 2021) incorporating changes to the NCSP Intermediate Risk Pathway.

Cancer Council Australia Cervical Cancer Screening Working Party. Clinical pathway: Cervical screening pathway. National Cervical Screening Program: Guidelines for the management of screen detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding. CCA 2016. Accessible from http://wiki.cancer.org.au/australia/Guidelines:Cervical_cancer/Screening. Updated Dec 2020.

There is a lack of evidence to show that women who have early sexual activity will benefit from screening commencing before age 25. ⁽⁵⁰⁾ However for those who experienced first sexual activity at a young age (<14 years) and who had not received the HPV vaccine before sexual debut, a single HPV test between 20 and 24 years of age could be considered on an individual basis. This includes those who are survivors of child sexual abuse.⁽⁵⁰⁾

For more information, see Cancer Council guidelines: Women experienced early sexual activity or victims of abuse.

Self-collected CST is when a patient collects their own vaginal swab for HPV testing without a speculum examination. This should be ordered and overseen by a healthcare professional, who is able to provide advice regarding the differences between self-collection and clinician-collected samples, advice about how to take a self-collected sample, and follow-up results (including obtaining a clinician-collected LBC if required). Patients attending consultations in-person should be encouraged to collect their sample while at the clinic, as it is more likely that samples will be collected and forwarded to the pathology laboratory in this context. Sample collection does not need to be supervised by the clinician and can be performed in the privacy of the bathroom or behind a curtain. Routine genital inspection is not recommended unless there is another clinical indication for this.⁽⁴⁷⁾

To perform a self-collected CST, advise patients to find a comfortable position and remove their underwear. Twist the cap and remove the swab from the protective sheath. The tip of the swab should be gently inserted a few centimetres into their vagina and gently rotated for 10-30 seconds. The swab can then be removed and placed back into the packaging and returned to their healthcare professional.

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To discuss results and facilitate decision-making:

Patients should be given clear and accurate information on the significance of the results and their choices for further management. Adequate time must be given to address any questions and to discuss any anxiety the patient may have about the significance of the abnormality and the management options. Easy-to-understand written material should be given to the patient to support verbal information provided. Adequate interpreter services should be available to patients for whom English is not their first language. Special care needs to be taken to ensure that they have understood the information and the management options. The management pathway should be based on the result of investigations and the patient’s preferences. The final treatment recommendations will be made by the specialist gynaecologist to whom the patient has been referred. The method of treatment will depend upon the local gynaecological expertise and available treatment modalities to the clinician, as well as the woman’s preferences. Explanations should occur at each stage of the assessment and treatment process.

Colposcopic examination should be undertaken only by a clinician specifically trained who is performing frequent and regular examinations and is a member of an appropriate society, group or forum in order to take part in regular updates, discussions, education, peer review and quality assurance activities. Colposcopic assessment should comply with the guidelines published by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and Australian Society for Colposcopy and Cervical Pathology (ASCCP).⁽⁴²⁾

The aim of colposcopy is to assess the nature, severity and extent of the screen-detected abnormality in order to enable appropriate management. Colposcopy is complemented by cytopathology and histopathology. The cytology report should be available at the time of colposcopy to enhance diagnostic accuracy.

If there is colposcopic evidence of a high-grade lesion, targeted biopsy is required for histological confirmation prior to definitive therapy. Patients with an abnormal CST should not be treated without prior colposcopic assessment. ⁽¹⁷⁾

For more information, see Cancer Council guidelines: Colposcopy

Patients who have a positive oncogenic HPV (any type) test result with a LBC report of either negative or pLSIL/LSIL, and histologically confirmed ≤ CIN1 on biopsy, should have a repeat HPV test 12 months later.⁽¹⁷⁾

For more information, see Cancer Council guidelines: Management of histologically confirmed low-grade squamous abnormalities.

The National Cancer Screening Register (NCSR) supports the delivery of the renewed NCSP as well as bowel screening programs. The NCSR has replaced the state and territory cervical cytology registries (also known as Pap test registers).

The National Cancer Screening Register:

Collects, analyses and reports information about individuals cervical screening history.⁽⁴³⁾ Has one record per person regarding their participation in cervical and bowel cancer screening to allow for ease of data access for clinicians, pathology laboratories and participants. Records Cervical Screening Test results and colposcopy data. Has a healthcare provider portal enabling clinicians to retrieve information about participation, screening history and to check if reminders were sent. Has a ‘consumer portal’ enabling people to access limited screening information, for example to check their due date for a Cervical Screening Test or to change their address. Participation can also be managed here, e.g. nominate a healthcare provider, defer next screening date, nominate a personal representative to access the register on their behalf. Provides an individual’s cervical screening history to pathology laboratories to inform recommendation for follow up or action. Issues letters of invitation to Australians who become eligible by age or are recently enrolled with Medicare e.g. new immigrants. Reminds individuals when they are due or overdue for

Family Planning NSW resources

Cervical Screening and HPV vaccination factsheets Talkline – phone: 1300 658 886

Online resources

National Cervical Screening Program (including information in different languages) National Cervical Screening Program – Toolkit for engaging under-screened and never-screened women in the National Cervical Screening Program Cancer Council Clinical Guidelines: Guidelines for the management of screen-detected abnormalities, screening in specific populations and investigation of abnormal vaginal bleeding Cancer Council: Summary of recommendation  World Health Organization (WHO) – Human papillomavirus (HPV) and cervical cancer  NPS MedicineWise – Learning modules on the changes to the National Cervical Screening Program Australian Institute of Health and Welfare – AIHW: National Cervical Screening Program monitoring report 2021 Drake R, Vogl AW, Mitchell AWM. Gray’s Anatomy for Students E-Book: Elsevier Health Sciences; 2009. Schiffman M, Castle PE, Jeronimo J, Rodriguez AC, Wacholder S. Human papillomavirus and cervical cancer. The Lancet. 2007;370(9590):890-907. Bateson D, Bower H, Stewart M. Cervical screening in the HPV era: don’t ditch the Pap test! 2011. Read C, May T, Stellingwerff M. How to Treat: Irregular Vaginal Bleeding Australian Doctor 2007;18(May):27 -34. Australian STI Management Guidelines for use in Primary Care [internet]. Australasian Sexual health Alliance. Cervicitis; 2018 [cited 2019 April 10]. Available from: http://www.sti.guidelines.org.au/syndromes/cervicitis#possible-causes. Royal College of Obstetricians and Gynaecologists. Cervical Polyp Removal [internet]. 2013. Available from: rcog.org.uk/en/guidelines-research-services/guidelines/cervical-polyp-removal—query-bank/. Younis M, Iram S, Anwar B, Ewies A. Women with asymptomatic cervical polyps may not need to see a gynaecologist or have them removed: an observational retrospective study of 1126 cases. European journal of Obstetrics, Gynaecology and reproductive Biology 2010;150(2):190-4. World Health Organisation (WHO). Human Papillomavirus (HPV) and Cervical Cancer. WHO [internet]. Available from: https://www.who.int/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer. Corpus Uteri [internet]. World Health Organization International Agency for Research on Cancer: World Health Organization; 2018. Australian Institute of Health and Welfare. Cervical Screening in Australia 2019. [Internet]. Canberra, ACT: Australian Institute of Health and Welfare; Available from: