What doctors wish patients knew about cervical cancer prevention

Cervical cancer because it is a slow-growing disease that rarely causes symptoms in its early stages, but it also is, fortunately, one of the few cancers that’s almost completely preventable. That’s because it comes down to being able to avoid the human papillomavirus (HPV), which can be detected in more than 90% of all cervical cancers, according to the Centers for Disease Control and Prevention (CDC). Yet the virus alone is not sufficient to cause cervical cancer—there are other contributing factors to keep in mind too.

Cervical cancer occurs when the cells on the cervix—the lower part of the uterus that connects to the vagina—grow and multiply, abnormally causing damage as they spread. Certain types of HPV are the main cause of cervical cancer. And while all women are at risk for cervical cancer, it happens most often in women older than 30, the CDC says.

About 13,000 new cases of cervical cancer are diagnosed in the U.S. each year, with Hispanic women having the highest rates of developing this cancer. Meanwhile, about 4,000 women a year die of cervical cancer, with Black women having the highest rates of dying from it, according to the CDC.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

For this installment, five ob-gyns took time to discuss what patients need to know about preventing cervical cancer. They are:

• Veronica Alvarez-Galiana, MD, medical director of ob-gyn services at Community Health of South Florida in Miami, and an alternate delegate in the AMA House of Delegates for the American College of Obstetricians and Gynecologists.
• Anthony Armstrong, MD, who practices in Toledo and is a delegate for the Ohio State Medical Association.
• Nariman Heshmati, MD, who practices at the Everett Clinic in Washington and is senior regional medical director for Optum Washington.
• Mary LaPlante, MD, who practices in Cleveland and serves on the AMA Council on Science and Public Health.
• Chemtai Mungo, MD, MPH, assistant professor of obstetrics and gynecology at the University of North Carolina School of Medicine.

“We are in a pivotal movement in history with current efforts by the World Health Organization to work towards eliminating cervical cancer through HPV vaccination and screening,” said Dr. Mungo. “So, we vaccinate girls and boys before they're sexually active so that when they get exposed to HPV,” they can be protected from most types of the virus.

“HPV causes more than nine out of 10 cervical cancers,” said Dr. Heshmati. “And HPV vaccination can prevent over 90% of HPV related cancers.”

“There are more than 100 HPV virus types,” said Dr. LaPlante. “Although the vaccine only protects against nine strains, it includes the ones that most commonly cause cervical cancer.”

“All girls and boys should get the HPV vaccine and can start the series as early as age 9 with general recommendations for routine vaccination at age 11–12,” said Dr. Heshmati. “It is recommended that anyone up to age 26 receive an HPV vaccine and some older than that may want to get it after discussing it with their physician.

“The benefit of getting the HPV vaccine later in life is lower since many people have already been exposed to HPV by then,” he added. “The only reasons not to get the HPV vaccine are if you have had a severe allergic reaction to the vaccine or a component of it before or if you are currently pregnant.”

“You actually want to give the vaccine to the adolescent before they have sexual intercourse. It is much more effective,” said Dr. Armstrong, noting “it is about 99% protective against cervical cancers.”

“I strongly urge people to get vaccinated. The vaccine is very, very safe and millions of people have gotten it,” said Dr. Mungo. “Many of those who first got the vaccine when it first came on the market 10, 15 years ago are now young women and adults who are having children, so the vaccine does not prevent you from having children.”

Additionally, “some people think that if you give a young girl the vaccine you are giving her license to be promiscuous. The science has not proven that,” she said, emphasizing that “the vaccine is absolutely safe and the vaccine literally saves lives because if you get the vaccine, you prevent your body from getting an HPV infection, which ultimately prevents you from getting cervical cancer.”

“Cervical cancer can be screened for with a Pap smear, HPV test or both,” said Dr. Alvarez-Galiana, noting that “usually if you are under 30 years old, you only get tested with the Pap smear, which is a sampling of the cells of the cervix.

“If you are over 30 then usually you are screened with both a Pap smear and for high-risk HPV,” she added. But “some doctors only screen with an HPV test.” 

“Pap smears are really important to get because they are an excellent screening tool for cervical cancer which happens to be the only gynecologic cancer that we have simple and reliable screening for,” said Dr. Heshmati, adding that “screening is also important because it can take years for normal cervical cells to become cancerous and often there are no symptoms during that early time.”

Dr. LaPlante added that “when a woman is getting proper screening, changes will be detected and can be treated before cancer ever develops.” But, she said, “if you have a normal Pap test or negative HPV test, it does not mean you do not have HPV—it can be sitting silent and cause changes later in your life even if you do not have a new partner for intercourse.”

Additionally, “once you have a positive HPV test, it does not mean it will always be positive,” Dr. LaPlante noted. “But it does mean you need to make sure you follow up as recommended by your physician.”

“The average healthy person who does not have a compromised immune system does not need to get screening every year,” said Dr. Mungo. “Based on the tests that you do, the average healthy person can actually get screened every five years.”

“Since cervical cancer is uncommon in women under 21, we recommend starting cervical cancer screening at age 21 with a Pap smear every three years,” said Dr. Heshmati. “Once over 30, women can continue pap smears every three years or spread them out to every five years by having either a Pap smear with HPV testing or an HPV test alone.”

“If you have had an abnormal pap test in the past, are taking medications that can affect your immunity or other considerations may change how often you need Pap tests,” said Dr. LaPlante. “Additionally, if you have had a hysterectomy with removal of your cervix, you do not need Pap testing any longer if your previous tests were normal.”

“Women over 65 can often stop screening if they have no history of abnormal cervical changes and a series of recent negative Pap or HPV tests,” said Dr. Heshmati, adding that “some women who have lower immune systems such as those with HIV may need more frequent screening.”

“Just because a doctor or other provider uses a speculum—the device that goes in the vagina during a pelvic exam to be able to see the cervix and obtain samples if needed—doesn’t mean that they had a Pap smear,” said Dr. Alvarez-Galiana, noting that “a speculum exam can be done for many reasons other than to get a Pap smear.

“For example, if you had a speculum exam in the ER, it is almost certain that you didn’t get a Pap smear. Most likely they were doing the speculum exam to help diagnose another condition related to the symptoms that brought you to the ER in the first place,” she added. “Patients are told their results are normal and they assume the Pap smear was done so then they think they don’t need to be screened,” but that is not the case.

“Anybody with a uterus and cervix is at risk of cervical cancer,” said Dr. Mungo, who noted that “some people were born with a uterus, but had part of the uterus removed for surgery, but if the cervix is still in your body, then you’re at risk of cervical cancer.”

“The most common risk is exposure to HPV, which is a sexually transmitted infection,” said Dr. Alvarez-Galiana. “Having multiple sexual partners, having a partner who has had multiple sexual partners, and having had an earlier age when becoming sexually active are associated with a higher risk of exposure to HPV.

“Other factors that increase the risk of cervical cancer are a history of abnormal Pap smears, smoking, HIV, other immunocompromised states, and having a mother who took diethylstilbestrol [a synthetic form of estrogen] during pregnancy,” she added.

“The more sexual partners you have, the more likely you'll be exposed to HPV, so you might keep getting exposed,” said Dr. Mungo. That’s because there are “multiple strains, which ultimately then your risk of continuing of HPV is higher.”

“Using a condom with partners, especially when young, is important to prevent all sexually transmitted infections, including HPV,” said Dr. Alvarez-Galiana. “HPV can also be spread during anal and oral sex so measures should be taken to prevent it using barrier methods.”

“If you’re a smoker, it does depress your immune system and you're not able to clear HPV,” said Dr. Mungo. “It basically has something to do with suppressing your immune system and the ability of your body to clear infections.”

In fact, invasive cervical cancer is up to three times more prevalent among women who smoke now or used to smoke, she explained. The risk rises with the duration and intensity of smoking. Exposure to secondhand smoke also increases the risk, but to a lesser extent.

“Not smoking is a great way to lower your risk for many diseases, including cervical cancer,” Dr. Alvarez-Galiana said.

“Early on, cervical cancer may not cause any symptoms and that is why cervical cancer screening is so important,” said Dr. Heshmati. “Once cervical cancer has started to result in symptoms, it likely has already started to spread.”

“The first signs of cervical cancer are often abnormal bleeding or watery vaginal discharge,” Dr. Heshmati explained, noting that “once cervical cancer is more advanced, symptoms may be more noticeable such as pelvic pain and difficulty peeing.”

Additionally, “when symptoms appear, they are most often heavy vaginal bleeding, bleeding in between periods or post-coital bleeding—bleeding during or after sex,” said Dr. Alvarez-Galiana.

“There’s about a five-to-10-year period—especially if you have a healthy immune system—when you have what we call pre-cervical cancer,” Dr. Mungo said.

“So when we do the Pap smear, we're really looking for abnormal cells under the microscope which have no symptoms,” she added. “And that is a stage where you can treat the pre-cancer and literally eliminate the possibility of this person getting cervical cancer.”

“If an abnormal Pap smear is found, the next step is a colposcopy, which is a procedure where a colposcope—microscope on wheels to look closely at the cervix—is used to look for abnormal cells on the cervix,” said Dr. Alvarez-Galiana. “A biopsy is taken and depending on the results, a repeat Pap is done within one year, or an excisional or ablative procedure is done.”

She added that “these procedures help prevent pre-cancerous lesions from continuing to develop into cancer.”

“When you are considering becoming sexually active or at 21 years old, you should begin yearly gynecological exams,” Dr. LaPlante said. “You should also see your ob-gyn if you have irregular bleeding, bleeding after intercourse or foul-smelling vaginal discharge.”

“Any time you have concerning symptoms such as vaginal bleeding, it is important to see your doctor,” said Dr. Heshmati. “Also, while you no longer need a Pap smear every year, it is still important to see your doctor every year to discuss other preventative screening and important aspects of your health care.”