Background Facts about Cervical Screening Cervical smears are used as a screening test to detect microscopic pre-cancerous changes in the cervix which are easily treated with few side-effects long before they may develop into a cancer of the cervix. Treatment therefore is preventative and noone need be afraid of it. The NHS Cervical Screening Programme An organized NHS screening programme has been in place in the UK since 1988 when computerized call-up of patients was introduced. This followed the introduction of similar systems in other Western countries. The aim of the programme was to reduce the incidence and reduce the number of deaths from cervical cancer. Despite much criticism and a few well publicised cases where the system failed a number of patients, overall the programme has proved to be a great success and has almost certainly prevented thousands of women developing and possibly dying from cervical cancer in the UK. Researchers have suggested that had it not been for the screening programme that the incidence of cervical cancer would now be climbing rather than continuing to fall as it is currently doing. However, despite this progress approximately 1000 women still die each year from this disease in England and Wales. The disease is particularly common in pre-menopausal adult women. It remains extremely important for all women to attend for smear tests when requested and to act on any abnormal results. What Exactly is a Smear Test? Cells shed from the surface of the cervix are examined under a microscope. Smears are usually taken by a nurse or doctor by performing a vaginal examination. A speculum enables a view of the cervix and upper vagina. A wooden spatula or alternatively a small brush is used to gently scrape cells off the surface of the cervix. Sometimes it is uncomfortable inserting the speculum into the vagina, but the taking of the smear itself should not hurt at all. Sometimes you may get some bleeding after this contact with the cervix. The cells from the cervix are then wiped on a glass slide and sprayed with a fixative solution before sending them on to the laboratory for analysis. Results are sent by post. This usually takes a number of weeks within the NHS, while private laboratories usually offer a faster service. Liquid-Based Cytology Increasingly liquid-based cytology (LBC) is being used for processing smears. With this new technique the cells are collected on a small broom and are rinsed off in a bottle of solution. The slides are made up in an automated process in the laboratory. In this way LBC reduces the chances of smears being inadequate for assessment, and hence reduces the need for smears being repeated unnecessarily. How Often Should I have a Smear? If you live in the UK you will be called up automatically for a smear test every 3 to 5 years depending on your age by the NHS. Since October 2003 the NHS has used a policy of calling people for a smear test as follows: 1st invitation at 25 years 25 – 49 years 3 yearly smears 50 – 64 years 5 yearly smears 65+ Only those who have not had a smear since 50 or have had recent abnormal tests Taking smears and analysing the results does have significant cost and resource implications for the NHS. Up until these guidelines were revised in 2003 women were called up for their first smear test from the age of 20 years. Research confirms that cervical cancer is very rare indeed under the age of 25 years, and yet accounts for a high proportion of colposcopy clinic activity. This results in a lot of anxiety, possible over treatment of some young women and significant cost to the public purse. Cervical cancer is most common in pre-menopausal adult women and the NHS has decided to focus attention and resources on women between the ages of 25 and 50 years with 3-yearly screening, reducing to 5-yearly screening up to 65 years. Other countries have different systems in place to prevent cervical cancer and often women are used to annual surveillance with either smears or colposcopy. In the UK this can only be accommodated within the private health sector. The exception to this is when a woman is being followed up after treatment for high grade smear abnormalities. Abnormal Smears Having an abnormal smear does not mean that you have cancer. This is very unlikely. Smear tests are intended to detect pre-cancerous cells and to prevent cancer developing. Any cells that are not completely normal are graded according to their abnormality: Borderline Mild Moderate Severe You may see the word dyskaryosis on your smear report or referral letter. This refers to the grade of abnormality of the cells seen on the smear. Some of these mild and borderline changes are related to inflammation due to viral infection in the cervix and often improves with time, or there may be no real underlying problem at all. This is why it is recommended to repeat smears when they are reported as borderline or mildly abnormal. The process of examining individual cells on a slide is called cytology. Are Abnormal Smears Caused by A Virus? Research has shown that most smear problems do arise following infection with a strain of human papilloma virus or HPV. This is contracted when you become sexually active. Condoms do protect against viral infections, but research has also shown that HPV infection is extremely common in the population. Hence infection alone is not the only problem. Cigarette smoking is an important factor which potentiates the effects of the viral infection, and stopping smoking can change the behaviour of the virus and is a positive measure which you can do yourself to help. For some young women HPV infection can cause persistent mild smear abnormalities. Often these problems resolve with time as your body’s immunity copes with the infection. Hence it may not always be necessary to treat you and close surveillance may be offered by your Consultant. There are certain subtypes of HPV which are higher risk than others. Some private laboratories do test for these high risk HPV types but the NHS has decided not to test for high risk HPV as a population screening method in favour of other strategies. Clinical trials are currently being conducted of vaccines against high risk HPV subtypes but the precise role of these vaccines is not yet known and they are unlikely to come into widespread clinical use for several years. Referral Criteria for Colposcopy These guidelines are usually used by your GP for referral to a colposcopy clinic to see a specialist: Borderline smear – Repeat at 6 months Mild dyskaryosis – Repeat at 6 months Moderate dyskaryosis – Colposcopy Severe dyskaryosis – Colposcopy Persistent borderline or mild dyskaryosis – Colposcopy Often women are referred for colposcopy if there is any other abnormality with the cervix or doubt about the diagnosis. What Is Colposcopy? Colposcopy is the detailed examination of the cervix and vagina under magnification. The colposcope is a specially adapted microscope with a bright light source. The doctor, or sometimes a specially trained nurse, will examine you and bathe the surface of the cervix with different solutions which stain any areas of abnormal skin on the cervix to highlight them. Cervical Biopsy The doctor may suggest a biopsy of the affected area to establish the diagnosis and to decide upon the most appropriate treatment, if any is required. You may experience a light spotting of blood following a biopsy for a couple of days. A cauterising stick of silver nitrate may leave a gritty grey/black discharge which can persist for a few days. You should avoid intercourse for 2 or 3 days afterwards to allow the biopsy site to heal. CIN Cervical intra-epithelial neoplasia (CIN) is the commonest abnormality in the cervical skin associated with abnormal smears. CIN is what we are trying to detect by taking smears. The diagnosis can only be confirmed by a biopsy or excision of the abnormal area on the cervix and by examining that small piece of that skin under the microscope. The degree of abnormality on a smear report (dyskaryosis) roughly equates with the grade of underlying CIN which is graded CIN1, CIN2 or CIN3 with increasing depth and degree of increasing severity. CIN is confined to the surface layer of cervical skin or epithelium and hence is not cancer. Simple treatment is therefore required. CGIN Cervical glandular epithelial neoplasia refers to similar abnormalities arising in the glandular cells which line the cervical birth canal. It is less common than CIN, and both processes may co-exist.