Makindo Medical Notes

Cervical cancer is a largely preventable malignancy, with almost all cases caused by persistent infection with high-risk human papillomavirus (hrHPV). Screening programmes aim to detect HPV infection and/or its cellular consequences before cancer develops, enabling early treatment of precancerous lesions. In the UK, the NHS Cervical Screening Programme uses primary HPV testing, which has significantly reduced both incidence and mortality from cervical cancer. All people with a cervix aged 25–64 are invited for regular screening, with intervals depending on age and HPV result. 🧑‍⚕️

🧬 Pathophysiology

• HPV is a DNA virus; high-risk types (e.g. 16, 18, 31) produce oncoproteins (E6, E7) that inactivate tumour suppressor genes (p53, Rb) → dysplasia → carcinoma in situ → invasive cancer.
• Most HPV infections in young people are transient and clear within 1–2 years. Only persistent hrHPV infection drives progression to cervical intraepithelial neoplasia (CIN) and carcinoma. 🔄
• Progression risk is influenced by cofactors: smoking 🚬, immunosuppression, long-term oral contraceptive use, high parity, early sexual debut.

⚙️ UK Cervical Screening Programme — Key Facts

• Eligible age: 25–64 years.
• Screening interval: From July 2025, those aged 25–49 who test hrHPV-negative will move to 5-yearly recall (previously 3-yearly). Those 50–64 are already on a 5-year interval.
• Primary HPV testing: Samples are tested for hrHPV first. • HPV negative → routine recall. • HPV positive → reflex cytology.
• Self-sampling: Planned rollout (~2026) in England for people less likely to attend conventional screening. 🧪

🔍 Risk Factors for Cervical Cancer / hrHPV Persistence

• Early onset of sexual activity and multiple partners.
• High-risk partner behaviour.
• Smoking 🚬.
• Immunocompromise (HIV, transplant, long-term steroids).
• Long-term OCP use, high parity.
• Poor attendance to screening / follow-up of abnormal results.
• Not vaccinated, or infected with non-vaccine HPV types.

🧪 Screening Process & Interpretation

• Sample collection: Cervical sample by trained clinician, or self-sampling (pilot phase).
• Laboratory testing: • HPV DNA test → if negative → routine recall. • HPV positive → reflex cytology for dyskaryosis.
• Possible outcomes: • HPV negative → routine recall. ✅ • HPV positive + normal cytology → repeat in 12 months; persistent positivity → colposcopy. • HPV positive + abnormal cytology → direct colposcopy. 🚨 • Inadequate sample → repeat in 3 months (if persistent → colposcopy).

⚠️ Exclusions & Modified Screening

• No cervix (total hysterectomy for benign disease) → no further screening.
• >65 years → only screened if recent abnormal results.
• Pregnancy → screening usually deferred; colposcopy safe if indicated.
• Immunosuppressed (HIV, transplant) → may require enhanced surveillance. 🧑‍⚕️

💉 Management of Abnormal Results

• Colposcopy: Magnified examination with biopsy if abnormality seen.
• Treatment: • CIN1 → often observe unless persistent. • CIN2/3 → excisional therapy (LLETZ) preferred.
• HPV vaccination: Preventive; offered to boys and girls at age 12–13 in the UK (single dose now standard). 💉
• Failsafe systems: National recall and safety-netting ensure abnormal results or inadequate samples are not missed.
• Risk factor modification: Encourage smoking cessation, safe sex practices, adherence to screening, and vaccination. 🌟

📊 Summary Table

Aspect	Details
Age range	25–64 years (England)
Interval if HPV negative	Every 5 years (change for ages 25–49 from 2025)
Primary test	High-risk HPV DNA test; cytology only if HPV positive
Abnormal result	HPV+ & abnormal cytology → colposcopy; HPV+ & normal cytology → repeat at 12 months
Vaccination	HPV vaccination (Gardasil 9) at age 12–13; protects against most oncogenic strains
Self-sampling	Rollout from 2026 for non-attenders

📚 Cases — Cervical Screening

• Case 1 (Normal smear): ✅ A 30-year-old woman attends routine screening. Cytology and HPV both negative. Management: Recall in 3 years (under age 50). Outcome: Reassured, routine follow-up.
• Case 2 (HPV positive, cytology negative): 🧬 A 36-year-old has hrHPV detected but normal cytology. Management: Repeat screening in 12 months. Outcome: HPV clears spontaneously at repeat; returned to 3-year recall.
• Case 3 (Abnormal cytology): 🚨 A 42-year-old has HPV+ smear with high-grade dyskaryosis and post-coital bleeding. Management: Urgent colposcopy → CIN3 confirmed → LLETZ excision performed. Outcome: Clear margins, “test of cure” (HPV + cytology) at 6 months negative.

🧑‍⚕️ Teaching Commentary

Cervical screening is one of the most effective cancer prevention strategies. 🌟 Key points: • HPV infection is necessary but not sufficient — persistence matters. • Primary HPV testing gives high negative predictive value → allows longer safe intervals. • Reflex cytology identifies those needing colposcopy. • Vaccination + screening together provide the strongest protection. Early detection of CIN saves lives and prevents invasive cervical carcinoma. 🩺