How are cervical cancers and pre-cancers diagnosed?
Signs and symptoms of cervical cancer
Women with early cervical cancers and pre-cancers usually have no symptoms. Symptoms often do not begin until the cancer becomes invasive and grows into nearby tissue. When this happens, the most common symptoms are:
- Abnormal vaginal bleeding, such as bleeding after vaginal intercourse, bleeding after menopause, bleeding and spotting between periods, and having (menstrual) periods that are longer or heavier than usual. Bleeding after douching or after a pelvic exam may also occur.
- An unusual discharge from the vagina − the discharge may contain some blood and may occur between your periods or after menopause.
- Pain during intercourse.
These signs and symptoms can also be caused by conditions other than cervical cancer. For example, an infection can cause pain or bleeding. Still, if you have any of these signs or other suspicious symptoms, you should see your health care professional right away. Ignoring symptoms may allow the cancer to progress to a more advanced stage and lower your chance for effective treatment.
Even better, don't wait for symptoms to appear. Have regular Pap tests and pelvic exams.
Your primary doctor can often treat pre-cancers and can often perform the colposcopy and biopsy to diagnose pre-cancers and cancers. If there is a diagnosis of invasive cancer, your doctor should refer you to a gynecologic oncologist, a doctor who specializes in cancers of women's reproductive systems.
Tests for women with symptoms of cervical cancer or abnormal Pap results
Medical history and physical exam
First, the doctor will ask you about your complete personal and family medical history. This includes information related to risk factors and symptoms of cervical cancer. A complete physical exam will help evaluate your general state of health. The doctor will do a pelvic exam and may do a Pap test if one has not already been done. In addition, your lymph nodes will be checked closely for evidence of metastasis (cancer spread).
The Pap test is a screening test, not a diagnostic test. An abnormal Pap test result may mean more testing, sometimes including tests to see if a cancer or a pre-cancer is actually present. The tests that are used include colposcopy (with biopsy) and endocervical scraping. If a biopsy shows a pre-cancer, doctors will take steps to keep an actual cancer from developing. Treatment of abnormal pap results is discussed in the section, "Treating pre-cancers and other abnormal Pap test results."
If you have certain symptoms that suggest cancer or if your Pap test shows abnormal cells, you will need to have a test called colposcopy. You will lie on the exam table as you do with a pelvic exam. A speculum will be placed in the vagina to help the doctor see the cervix. The doctor will use a colposcope to examine the cervix. The colposcope is an instrument (that stays outside the body) that has magnifying lenses (like binoculars). It lets the doctor see the surface of the cervix closely and clearly. The doctor will apply a weak solution of acetic acid (similar to vinegar) to your cervix to make any abnormal areas easier to see.
Colposcopy itself causes no more discomfort than any other speculum exam. It has no side effects and can be done safely even if you are pregnant. Like the Pap test, it is better not to do it during your menstrual period. If an abnormal area is seen on the cervix, a biopsy will be done. For a biopsy, a small piece of tissue is removed from the area that looks abnormal. The sample is sent to a pathologist to look at under a microscope. A biopsy is the only way to tell for certain whether an abnormal area is a pre-cancer, a true cancer, or neither. Although the colposcopy procedure is usually not painful, the cervical biopsy can cause discomfort, cramping, or even pain in some women.
Several types of biopsies are used to diagnose cervical pre-cancers and cancers. If the biopsy can completely remove all of the abnormal tissue, it might be the only treatment needed.
Colposcopic biopsy: For this type of biopsy, first the cervix is examined with a colposcope to find the abnormal areas. Using a biopsy forceps, a small (about 1/8-inch) section of the abnormal area on the surface of the cervix is removed. The biopsy procedure may cause mild cramping, brief pain, and some slight bleeding afterward. A local anesthetic is sometimes used to numb the cervix before the biopsy.
Endocervical curettage (endocervical scraping): Sometimes the transformation zone (the area at risk for HPV infection and pre-cancer) cannot be seen with the colposcope. In that situation, something else must be done to check that area for cancer. This means taking a scraping of the endocervix by inserting a narrow instrument (called a curette) into the endocervical canal (the part of the cervix closest to the uterus). The curette is used to scrape the inside of the canal to remove some of the tissue, which is then sent to the laboratory for examination. After this procedure, patients may feel a cramping pain, and they may also have some light bleeding.
Cone biopsy: In this procedure, also known as conization, the doctor removes a cone-shaped piece of tissue from the cervix. The base of the cone is formed by the exocervix (outer part of the cervix), and the point or apex of the cone is from the endocervical canal. The transformation zone (the border between the exocervix and endocervix) is the area of the cervix where pre-cancers and cancers are most likely to start, and is contained within the cone specimen. The cone biopsy can also be used as a treatment to completely remove many pre-cancers and some very early cancers. Having had a cone biopsy will not prevent most women from getting pregnant, but if a large amount of tissue has been removed, women may have a higher risk of giving birth prematurely.
There are 2 methods commonly used for cone biopsies: the loop electrosurgical excision procedure (LEEP; also called large loop excision of the transformation zone [LLETZ]) and the cold knife cone biopsy.
- Loop electrosurgical procedure (LEEP, LLETZ): In this method, the tissue is removed with a thin wire loop that is heated by electrical current and acts as a scalpel. For this procedure, a local anesthetic is used, and it can be done in your doctor's office. It takes only about 10 minutes. You might have mild cramping during and after the procedure, and mild-to-moderate bleeding for several weeks.
- Cold knife cone biopsy: This method uses a surgical scalpel or a laser instead of a heated wire to remove tissue. You will receive anesthesia during the operation (either a general anesthesia, where you are asleep, or a spinal or epidural anesthesia, where an injection into the area around the spinal cord makes you numb below the waist) and is done in a hospital, but no overnight stay is needed. After the procedure, cramping and some bleeding may last for a few weeks.
How biopsy results are reported
The terms for reporting biopsy results are slightly different from The Bethesda System for reporting Pap test results. Pre-cancerous changes are called cervical intraepithelial neoplasia (CIN) instead of squamous intraepithelial lesion (SIL). CIN is graded on a scale of 1 to 3 based on how much of the cervical tissue looks abnormal when viewed under the microscope. In CIN1, not much of the tissue looks abnormal, and it is considered the least serious cervical pre-cancer. In CIN2 more of the tissue looks abnormal, and in CIN3 most of the tissue looks abnormal. CIN3 is the most serious pre-cancer.
Sometimes the term dysplasia is used instead of CIN. CIN1 is the same as mild dysplasia, CIN2 is the same as moderate dysplasia, and CIN3 includes severe dysplasia as well as carcinoma in situ.
The terms for reporting cancers (squamous cell carcinoma and adenocarcinoma) are the same for Pap tests and biopsies.
Diagnostic tests for women with cervical cancer
If a biopsy shows that cancer is present, your doctor may order certain tests to see how far the cancer has spread. Many of the tests described below are not necessary for every patient. Decisions about using these tests are based on the results of the physical exam and biopsy.
Cystoscopy, proctoscopy, and examination under anesthesia
These are most often done in women who have large tumors. They are not necessary if the cancer is caught early.
In cystoscopy a slender tube with a lens and a light is placed into the bladder through the urethra. This lets the doctor check your bladder and urethra to see if cancer is growing into these areas. Biopsy samples can be removed during cystoscopy for pathologic (microscopic) testing. Cystoscopy can be done under a local anesthetic, but some patients may need general anesthesia. Your doctor will let you know what to expect before and after the procedure.
Proctoscopy is a visual inspection of the rectum through a lighted tube to check for spread of cervical cancer into your rectum.
Your doctor may also do a pelvic exam while you are under anesthesia to find out if the cancer has spread beyond the cervix.
If your doctor finds that you have cervical cancer, certain imaging studies may be done. These include magnetic resonance imaging (MRI) and computed tomography (CT) scans. These studies can show whether the cancer has spread beyond the cervix.
Chest x-ray: Your chest may be x-rayed to see if cancer has spread to your lungs. This is very unlikely unless the cancer is far advanced. If the results are normal, you probably don’t have cancer in your lungs.
Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body (think of a loaf of sliced bread). The machine takes pictures of multiple slices of the part of your body that is being studied. CT scans can help tell if your cancer has spread to the lymph nodes in the abdomen and pelvis. They can also be used to see if the cancer has spread to the liver, lungs, or elsewhere in the body.
Before the first set of pictures is taken you may be asked to drink 1 to 2 pints of a contrast liquid. You may also receive an IV (intravenous) line through which a different kind of contrast is injected. This helps better outline structures in your body.
The IV contrast can cause your body to feel flushed (a feeling of warmth with some redness of the skin). A few people are allergic to the dye and can get hives. Rarely, more serious reactions, like trouble breathing and low blood pressure, can occur. You can be given medicine to prevent and treat allergic reactions, so be sure to tell your doctor if you have ever had a reaction to contrast material used for x-rays. It is also important to let your doctor know about any other allergies.
CT scans take longer than regular x-rays and you will need to lie still on a table while they are being done. Also, you might feel a bit confined by the ring-like equipment you’re in when the pictures are being taken.
CT scans are sometimes used to guide a biopsy needle precisely into an area of suspected cancer spread. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ½-inch long and less than 1/8-inch in diameter) is removed and examined under a microscope.
Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays to take pictures. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross sectional slices of the body like a CT scanner, it can also produce slices that are parallel with the length of your body.
MRI images are particularly useful in examining pelvic tumors. They are also helpful in detecting cancer that has spread to the brain or spinal cord.
A contrast material might be injected into a vein just as with CT scans, but is used less often. MRI scans take longer than CT scans − often up to an hour. Also, you have to be placed inside a tube-like piece of equipment, which is confining and can upset people with claustrophobia (a fear of enclosed spaces). Special, “open” MRI machines that are not so confining may be an option for some patients; the downside of these is that the images may not be as good. The machine also makes a thumping noise that some people find disturbing. Some places provide headphones with music to block this noise out. A mild sedative is helpful for some people.
Intravenous urography: Intravenous urography (also known as intravenous pyelogram, or IVP) is an x-ray of the urinary system taken after a special dye is injected into a vein. This dye is removed from the bloodstream by the kidneys and passes through the ureters and into the bladder (the ureters are the tubes that connect the kidneys to the bladder). This test finds abnormalities in the urinary tract, such as changes caused by spread of cervical cancer to the pelvic lymph nodes, which may compress or block a ureter. IVP is rarely used currently to evaluate patients with cervical cancer. You will not usually need an IVP if you have already had a CT or MRI.
Positron emission tomography: Positron emission tomography (PET) uses glucose (a form of sugar) that contains a radioactive atom. Cancer cells in the body absorb large amounts of the radioactive sugar and a special camera can detect the radioactivity. This test can help see if the cancer has spread to lymph nodes. PET scans can also be useful if your doctor thinks the cancer has spread but doesn’t know where. PET scans can be used instead of other types of x-rays because they scan your whole body. Some machines combine a CT scan and a PET scan to even better pinpoint the tumor. This test is rarely used for patients with early cervical cancer, but may be used to look for more advanced disease.
Last Medical Review: 04/11/2013
Last Revised: 01/31/2014