Version May 2024
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INTRODUCTION — Screening for cervical cancer has greatly reduced the rates of cervical cancer. Screening with Pap and/or human papillomavirus (HPV) tests is recommended starting between the ages of 21 and 25 years. Any person with a cervix should be screened, regardless of gender identity, sexual orientation, or sexual activity. (See "Patient education: Cervical cancer screening (Beyond the Basics)".)
People who have abnormal screening results (indicating possible precursors to cervical cancer) need further follow-up or treatment.
Precancerous results are further evaluated with colposcopy, a procedure done in your clinician's office during a pelvic examination with a special microscope. During the colposcopy, the clinician looks at the cervix and biopsies any areas that look abnormal. Also, sometimes an endocervical curettage (ECC) is done; this is a sampling of cells from the cervical canal. The results of the biopsies and ECC show if you have precancer or cancer of the cervix. The colposcopy procedure is described in more detail separately. (See "Patient education: Colposcopy (Beyond the Basics)".)
Depending on which cells are involved, the abnormality is referred to as "cervical intraepithelial neoplasia" (CIN) or "adenocarcinoma in situ" (AIS):
●CIN – The outer surface of the cervix is composed of cells called squamous cells. A precancerous lesion affecting these cells is called CIN. These changes are categorized as being mild (CIN 1) or moderate to severe (CIN 2 or 3).
●AIS – The canal of the cervix is lined with glandular cells. A precancerous lesion affecting these cells is called AIS.
Treatments for precancerous lesions include excision (surgical removal of the abnormal area, also referred to as a cone biopsy or conization, or loop electrosurgical excision procedure [LEEP]), cryosurgery (freezing), and laser (high-energy light). (See "Patient education: Colposcopy (Beyond the Basics)".)
The tests performed to evaluate abnormal Pap tests are discussed separately. (See "Patient education: Cervical cancer screening (Beyond the Basics)" and "Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)" and "Patient education: Follow-up of high-grade or glandular cell abnormal Pap tests (Beyond the Basics)".)
Treatment of cervical cancer is also discussed in a separate topic. (See "Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)".)
MANAGEMENT OF LOW-GRADE CIN — Low-grade squamous lesions (cervical intraepithelial neoplasia [CIN] 1) usually resolve but must be followed to make sure that they do not progress to high-grade lesions or cancer. CIN 1 is managed based on the Pap test and human papillomavirus (HPV) test findings that preceded them since these test results provide information about the risk of developing a more severe lesion. Your doctor will talk to you about the best course of action for your situation, but the following are general guidelines.
●For CIN 1, if you had prior testing that was less concerning (including a Pap with atypical squamous cells of undetermined significance [ASC-US], low-grade squamous intraepithelial lesion [LSIL], or atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion [ASC-H]), the guideline is (see "Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)"):
•If you are age 25 and older, you should have an HPV test with or without a Pap test in one year. If your follow-up testing is abnormal, colposcopy is done. If your CIN 1 persists for two years, you might continue to have regular testing or you might get treatment. Your doctor will help you decide.
•If you are age 21 to 24, you should have a Pap test in one year. HPV testing is not usually part of cervical cancer screening for people in this age group because HPV infection usually goes away on its own in young people and their risk of high-grade lesions or cervical cancer is low. If the follow-up Pap test shows high-grade abnormal cells (ASC-H) or high-grade squamous intraepithelial lesion (HSIL), colposcopy is done.
●For CIN 1, if you had an HSIL Pap test beforehand, the guideline is (see "Patient education: Follow-up of high-grade or glandular cell abnormal Pap tests (Beyond the Basics)"):
•If you are age 25 and older, your follow-up can be one of two options: (1) colposcopy and an HPV test (with or without a Pap test) in one year or (2) immediate treatment with a procedure to remove a larger piece of tissue from your cervix (cone biopsy or loop electrosurgical excision procedure [LEEP], also called large loop excision of the transformation zone [LLETZ]).
•If you are age 21 to 24, you should have both a colposcopy and a Pap test in one and two years. If you have a follow-up HSIL Pap or a biopsy with a high-grade lesion (CIN 2 or 3), you may need treatment with a LEEP or cone biopsy.
MANAGEMENT OF HIGH-GRADE CIN — High-grade squamous lesions (cervical intraepithelial neoplasia [CIN] 2 or 3) have a high risk of persisting or developing into cervical cancer over a period of years.
●If you are age 25 and older and not pregnant, CIN 2 or 3 is treated by removing or destroying the abnormal area.
●If you are age 21 to 24 and not pregnant, CIN 2 can be closely monitored with Pap tests, human papillomavirus (HPV) testing, and colposcopy (this is the preferred approach), but treatment is also acceptable. CIN 3 is treated by removing or destroying the abnormal area.
●If you are pregnant, you should delay treatment until after giving birth unless cancerous cells are present, regardless of your age.
If you think you may want to get pregnant in the future, it is important to be aware that some types of treatment for cervical precancer may increase the risk of preterm delivery or other complications during a future pregnancy. Your health care provider can talk to you more about these risks. (See 'Choosing the best treatment for precancer of the cervix' below.)
MANAGEMENT OF ADENOCARCINOMA IN SITU — Adenocarcinoma in situ (AIS) is a precancerous lesion of the glands of the cervix. Glandular cells are found in the lining of the cervical canal. The diagnosis of AIS is made based on a biopsy of the cervix. This may follow an evaluation for a finding of atypical glandular cells (AGC) on a Pap test. AIS is a precancer, but it may lead to cancer (adenocarcinoma of the cervix). Glandular cancers of the cervix are less common than squamous cancers.
If adenocarcinoma is found, this may be treated with hysterectomy (surgical removal of the cervix, uterus, and surrounding tissues) or an excisional procedure (this is a larger biopsy of the cervix, also called a cone biopsy or conization). Hysterectomy is the preferred treatment, but people who are still planning to become pregnant in the future may choose conservative treatment with an excisional procedure. For those who choose conservative management, a repeat excisional procedure may be necessary if the initial excision results show there may still be some AIS cells remaining in the cervix. After an excisional procedure, follow-up consists of a Pap test, human papillomavirus virus (HPV) test, and endocervical curettage every six months for three years.
CHOOSING THE BEST TREATMENT FOR PRECANCER OF THE CERVIX — Precancers of the cervix are treated by identifying the area of abnormal cervical tissue and removing it to prevent worsening or spread to other areas of the cervix. There are two main types of treatment for cervical abnormalities:
●Treatments that remove the abnormal areas (called excisional therapy, cervical conization, cone biopsy, loop electrosurgical excision procedure [LEEP], and large loop excision of the transformation zone [LLETZ]).
●Treatments that destroy the abnormal area (called ablative therapy).
In the United States, excision, specifically with LEEP, has largely replaced the practice of ablation.
EXCISION — In an excisional procedure, the abnormal area on the surface of the cervix is cut out; excision can also remove abnormalities that extend inside the cervical opening. Excisional therapy is recommended when the extent or type of cervical abnormality is not clear based on colposcopy and biopsy or when there is a severe abnormality.
Excision serves two purposes:
●It provides a sample of tissue to confirm the degree of an abnormality and check for cancerous or precancerous cells deep within the cervix.
●The goal of excision is to remove the abnormality completely. If the edges of the tissue that is removed show evidence that some of the abnormality or precancer may have been left behind, further treatment may be needed.
Excision can be done in the clinician's office or operating room. The cervix is injected with local anesthesia to prevent pain. You may feel a dull ache or cramp during the procedure. A brown paste is applied after the treatment to prevent bleeding; this often causes a dark vaginal discharge (similar to coffee grounds). Most people are able to return to work or school the same day or the day after the procedure.
Following a cervical excision, most people have mild to moderate vaginal bleeding and discharge for one to two weeks. The bleeding should not be heavy (eg, should not soak a pad in less than one hour). Care after excision is described below. (See 'Postprocedure care' below.)
Loop electrosurgical excision procedure — Excision can be done in the clinician's office or in the operating room with an electrical cutting loop. This is called a loop electrosurgical excision procedure (LEEP) or large loop excision of the transformation zone (LLETZ). A thin wire loop is inserted through the vagina, where it uses an electric current to remove a cone-shaped portion of the cervix.
Cone biopsy — Excision can also be done with a scalpel instead of a loop; this is called a cone biopsy or cold knife conization (figure 1). This procedure is usually done in an operating room after the patient has received general anesthesia (medicine given to induce sleep) or regional anesthesia (eg, epidural or spinal).
Another option for conization is with a laser knife, which uses high-intensity energy from a light beam. This technique is not commonly used.
Complications — As with any surgical procedure, complications can occur during or following excision. Possible complications include bleeding during or after the procedure, infection, and perforation of the uterus (although this is rare).
ABLATIVE TREATMENTS — Ablative treatments destroy rather than cut away the abnormal cervical tissue. Ablative therapy may be recommended when there is less concern about cancer or about the extent of the abnormal tissue.
Cryosurgery — Cryosurgery involves applying liquid nitrogen or carbon dioxide to the cervix. This causes the cervical tissue to freeze, which destroys the abnormal cells. Cryosurgery can be done in the office without any anesthesia. It may cause mild cramping or discomfort.
Cryosurgery is not recommended in certain situations, such as when the extent or type of cervical abnormality is not clear based on colposcopy and/or biopsy. Excisional therapy is preferred in most cases.
Most people have watery vaginal discharge for one week after cryosurgery. Care after cryosurgery is described below. (See 'Postprocedure care' below.)
Laser ablation — Laser ablation uses high-intensity energy from a light beam to destroy abnormal areas of the cervix. The laser is directed to the abnormal area of the cervix through the vagina. This is usually performed in an operating room under general anesthesia or with regional anesthesia (eg, epidural or spinal). Laser treatment requires special training and equipment.
Like cryosurgery, laser ablation destroys the abnormal tissue, which means that the tissue cannot be examined under a microscope and analyzed. As a result, laser ablation is not recommended in certain situations, such as when the extent or type of cervical abnormality is not clear based on colposcopy and/or biopsy.
Most people have vaginal discharge for one to two weeks after laser treatment. Care after laser treatment is described below. (See 'Postprocedure care' below.)
POSTPROCEDURE CARE — Your health care provider will talk to you about activities to avoid after your procedure, including whether you will be able to drive yourself home afterwards and when you can resume your normal daily activities. Following treatment, most providers recommend avoiding sexual intercourse, not placing anything in the vagina (eg, douches, tampons), and not taking a bath or swimming for a few weeks (showers are fine). Your provider can talk to you in more detail about what activities to avoid and any other cautions you should take.
In general, you should call your provider if you have bleeding that is heavier than a normal menstrual period (defined as soaking a pad in less than one hour, especially if there are clots), severe or worsening pain, fever of 101°F (38.4°C) or higher, or a foul-smelling vaginal discharge.
Follow-up appointments — Typically, you will be seen for a follow-up examination several weeks after treatment to make sure your cervix is healing.
After treatment, further follow-up is needed to ensure that the lesion is cured. This will involve Pap tests, and possibly human papillomavirus (HPV) testing, every 6 to 12 months. The exact schedule for follow-up is best discussed with your clinician since it may vary from one person to another.
Once the precancer has been fully treated and Pap tests return to normal, routine screening is recommended for at least 25 years, even if screening continues beyond age 65 years.
Treatment efficacy — The treatments described above are effective, but recurrence or persistence of cervical precancer occurs in up to 30 percent of cases. People who are not cured after a first treatment may have persistence, recurrence, or progression of the abnormality, especially if a high-risk type of HPV, type 16 or 18, is present. For this reason, long-term follow-up with cervical cytology smears (Pap test) is important. Additional treatment is sometimes needed. The decision to have additional treatment is based on the type of abnormality seen, your risk of cervical cancer, and whether or not you may want to get pregnant in the future. (See "Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)".)
PREGNANCY AFTER TREATMENT FOR ABNORMAL PAP SMEAR — Many people are concerned about the risks of infertility and preterm labor after being treated for an abnormal Pap test. Treatments do not seem to affect fertility; however, with some types of treatment, there may be some risk of complications during a future pregnancy. In general, studies suggest that excisional procedures slightly increase the risk of preterm delivery, but ablative procedures do not. Other factors, such as underlying medical conditions and your age, can also increase your risk of pregnancy issues.
Most people are advised to wait at least three months after a cervical ablation or excision before attempting to become pregnant to allow the tissue to heal fully. (See "Patient education: Preterm labor (Beyond the Basics)", section on 'Cervical length'.)
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Cervical cancer (The Basics)
Patient education: Cervical cancer screening tests (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Cervical cancer screening (Beyond the Basics)
Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)
Patient education: Follow-up of high-grade or glandular cell abnormal Pap tests (Beyond the Basics)
Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)
Patient education: Preterm labor (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing
Cervical cancer screening: Risk assessment, evaluation, and management after screening
Cervical cytology: Evaluation of atypical and malignant glandular cells
Cervical intraepithelial neoplasia: Management
Screening for cervical cancer in resource-rich settings
The following organizations also provide reliable health information.
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
●National Cancer Institute
●American Society for Colposcopy and Cervical Pathology
●American Cancer Society
(www.cancer.org, search for HPV)
●Center for Disease Control and Prevention
ACKNOWLEDGMENT — The authors and editors would like to recognize Dr. William J Mann, Jr., who contributed to previous versions of this topic review.
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