Cervical Dysplasia

Cervical pre-cancer, also known as cervical dysplasia or cervical intrapepithelial neoplasia, is an abnormal change in the surface of the cervix. The cervix is the lower part of the uterus (also known as the womb) that connects to the vagina. These changes are classified as low grade or high grade. Most cases of dysplasia can be cured with proper treatment and follow-up. If left untreated, cervical dysplasia can sometimes progress to cervical cancer.

Almost all cases of cervical pre-cancer are caused by high-risk types of the human papillomavirus (also known as HPV). HPV is the most common sexually transmitted infection in the United States. The majority of women will have an HPV infection at some point in their lifetime. When a woman has an HPV infection, her body’s immune system will usually clear the infection on its own, before the virus can cause harm to the cells of the cervix. However, sometimes the infection remains for several months or years, and can potentially cause cervical dysplasia or pre-cancer, which can become cancer if they are not treated.

Between 250,000 and 1 million women are diagnosed with cervical dysplasia in the United States every year. Most cases of cervical dysplasia develop in women between the ages of 25 and 35, although it can occur at any age. Older women can still develop cervical cancer, even if they are no longer sexually active. It is very rare for cervical dysplasia to develop in women younger than age 21.

Risk Factors

There are several risk factors for developing cervical pre-cancer and cancer:

  • HPV infection – this is the most important risk factor for cervical dysplasia and cervical cancer. The risk of getting an HPV infection can be reduced by using barrier contraception during sexual intercourse, such as male and female condoms and dental dams. Currently there is no treatment or cure for an HPV infection.
  • Sexual history – because HPV is a sexually transmitted infection, and is the primary cause of cervical dysplasia and cervical cancer, a woman’s sexual history is a risk factor for developing cervical cancer. The higher the number of sexual partners a woman has, and the younger the age a women starts to have sex, the higher the risk of getting an HPV infection and developing cervical dysplasia and cervical cancer.
  • Smoking – smoking cigarettes increases your chances of developing cervical dysplasia. Chemicals associated with smoking can be found in the mucus of the cervix, and can contribute to the development of cervical dysplasia. Smoking also makes it more difficult for the body’s immune system to fight off an HPV infection.
  • A weak immune system – women who have weak immune systems, such as women with HIV or women who are taking immunosuppressive medications, are at increased risk of developing cervical dysplasia because this makes it more difficult for the body’s immune system to fight off an HPV infection.
  • Other sexually transmitted infections – women with sexually transmitted infections other than HPV, such as chlamydia, gonorrhea, syphyllis, or herpes, have a higher risk of developing cervical dysplasia.

Prevention

Cervical dysplasia can be prevented by getting the HPV vaccine, avoiding risk factors, and by having regular cancer screening between the ages of 21 and 65. The HPV vaccine is safe. It is effective in protecting against the most common high risk strains of HPV that cause cervical cancer. The Advisory Committee on Immunization Practices (ACIP) recommends that all girls and boys get the HPV vaccine at age 11 or 12 years, although vaccination start as early as 9 years. The HPV vaccine is also recommended for females through age 26 and for males through age 21 who were not vaccinated previously. Males may also be vaccinated through age 26.

Symptoms

Women with an HPV infection or cervical dysplasia often don’t have any signs or symptoms. Symptoms usually don’t start until the cervical dysplasia becomes a cancer. These symptoms can include:

  • Pelvic pain
  • Pain during intercourse
  • Vaginal bleeding or spotting after vaginal intercourse, bleeding or spotting in between menstrual periods, bleeding or spotting after menopause, or menstrual periods that are heavier or last longer than usual.
  • Vaginal discharge that can be watery, bloody, or have a foul odor


If you have any of these symptoms, it is important that you see a doctor or other health care professional immediately. Ignoring symptoms may allow the condition to become more advanced. It is best that you get regular screening tests for cervical cancer before you develop any symptoms.

Screening

The two screening tests for cervical dysplasia are the Pap test (also known as the Pap smear) and HPV test. The Pap smear is performed during a pelvic exam.

A pelvic exam is an internal exam of the female reproductive tract and surrounding organs. This includes the uterus, cervix, vagina, ovaries, fallopian tubes, bladder and rectum. The first step is for you to lie down on an examination table and put your feet in stirrups. Next, an instrument called a speculum is inserted into your vagina to hold your vaginal walls open so your healthcare provider can view the inside of the vaginal walls and the cervix, and collect a sample of cervical tissue for your Pap test.

Once the speculum is inserted into the vagina, and the cervix is visible to the healthcare provider, the Pap test is performed by using a plastic spatula to gently scrape the surface of the cervix. This action collects cells from the surface of the cervix. A small brush is then inserted into the cervical canal in order to collect cells from the inside of the cervix. These cells are then collected in a special fluid that allows the cells to be evaluated under a microscope to tell if there are any abnormal changes, or cervical dysplasia. Getting a Pap test only takes a few minutes and is usually not painful. The same sample of cells in the special fluid can be used to test for HPV.

Screening recommendations depends on your age. The American Cancer Society and the American Society for Cervical Cytology and Pathology recommend starting cervical cancer screening at age 21, regardless of the age when a woman becomes sexually active. Women who are less than 21 years old should not get cervical cancer screening with a Pap test or and HPV test.

Women aged 21 to 29 years should be screened for cervical cancer with a Pap test every 3 years if their prior Pap tests have been normal. For some women, an HPV test may be done in order to guide management of certain abnormal Pap test results.

Women aged 30 – 65 years should be screened for cervical cancer with both a Pap test and an HPV test. When the Pap and HPV test are automatically done together, this is called co-testing. Co-testing is recommended every 5 years if both the Pap and the HPV test are normal. Women need to continue to get screened for cervical cancer regardless of whether or not they are sexually active.

Women older than 65 years do not need cervical cancer screening if all of their recent cervical cancer screening tests have been normal. Women with a history of cervical pre-cancer need to continue to get screening for 20 years after they were treated for the pre-cancer. Women who have had a hysterectomy (who no longer have a cervix) and who do not have a history of cervical pre-cancer do not need cervical cancer screening.

Diagnosis

If cervical dysplasia is suspected because of abnormal screening tests or worrisome symptoms, your health care provider will perform a thorough evaluation of your cervix with a colposcopy. A colposcopy examination is simply looking at your cervix with an electric magnifying instrument to look for abnormal cells. Similar to a pelvic exam, the first step is for you to lie down on an examination table and put your feet in stirrups. Next, an instrument called a speculum is inserted into your vagina to hold your vaginal walls open so your healthcare provider can view the inside of the vaginal walls and the cervix. Next, special solutions will be applied to the cervix to accentuate any abnormal changes. Then, your healthcare provider will look at your cervix through the colposcope, which shines a light on and magnifies your cervix. If your health care provider sees any abnormal changes, then he or she will take a biopsy, or a small sample, of the abnormal area. They may also take a more deeper and thorough scraping of the inside of the cervical canal. This is called an endocervical curettage, or ECC.

Depending on the results of the colposcopy, biopsy, or ECC, your healthcare provider will recommend either treatment or close follow-up. If a biopsy or ECC confirms cancer, you should be seen immediately by a gynecologic oncologist. A gynecologic oncologist is a women’s cancer specialist. They may recommend further tests to see if the cancer has spread to other parts of the body.

Treatment

The New York Center for Lower Genital Tract Diseases works with each woman to develop a treatment plan that is best suited to their particular needs and preferences, as well as deliver the most up to date and state of the art treatment. Treatment for lower genital tract diseases, including cervical dysplasia, will depend on the type and severity of the dysplasia. The treatment plan will also be determined based on your overall health and medical history, and your tolerance for specific procedures, medications, or therapies.

If you have been found to have high-grade cervical dysplasia, your healthcare provider may recommend that the area of dysplasia be removed. The two most common procedures for removing areas of dysplasia are the loop electrosurgical excision procedure (LEEP) or cold knife conization.

The LEEP can be performed either in the doctor’s office or as an outpatient procedure in the operating room. Similar to a pelvic exam, the first step is for you to lie down on an examination table and put your feet in stirrups. Next, an instrument called a speculum is inserted into your vagina to hold your vaginal walls open so your healthcare provider can view the inside of the vaginal walls and the cervix. The cervix is then numbed by injecting it with a local anesthetic medication. An electrically charged loop made of thin wire is inserted into the vagina and up to the cervix. The loop is passed across the cervix, cutting away a portion of the surface of the cervix. The goal is to remove the entire area of dysplasia. If all of the abnormal cervical tissue is removed, no further surgery is needed. However, because cervical dysplasia can come back in the future, it is important to get close follow-up by a healthcare provider. The entire LEEP, including preparation, usually takes about 5 minutes. Patients usually experience only slight discomfort.

A cold knife conization is a minor surgery that entails removing a cone-shaped portion of the cervix with a scalpel. It is performed in the operating room under anesthesia. Similar to a pelvic exam, this procedure is preformed with you lying down on an examination table with your feet in stirrups. Next, an instrument called a speculum is inserted into your vagina to hold your vaginal walls open so your healthcare provider can view the inside of the vaginal walls and the cervix. The doctor will then remove a small, cone-shaped area of the cervix.

Follow-up

Almost all cases of cervical dysplasia can be cured with early diagnosis and prompt treatment. Some cases of severe dysplasia can develop into cervical cancer if left untreated. Cervical dysplasia can come back, or recur, in the future, especially if a woman has a persistent HPV infection. It is important to follow medical advice regarding when to follow-up, either after an abnormal Pap or HPV test result, or after treatment for cervical dysplasia. You may need frequent follow-up with Pap and/or HPV tests, or even repeat colposcopy examinations, every few months for the first couple of years following treatment for cervical dysplasia. At the New York Center for Lower Genital Tract Diseases, our treatment plan recommendations are based on the most up to date clinical guidelines, as well as your needs and preferences.