Dr Soheila Amini Moghadam
Gynecology, Obstetrics and Infertility Surgeon, Gynecology Oncology Fellowship
In this video, Dr Soheila Amini Moghadam Gynecology and Obstetrics specialist, speeches about malignant cervical cancer disease, explained about Cervical cancer; prevention, diagnosis and treatment.
The text of Dr. Amini Moghadam‘s speech
In the name of God, greetings. I want to talk to you about cervical cancer. The main factor in creating premalignant and malignant changes of the cervix is a virus. The name of this virus is human papilloma virus or HPV.
How does HPV occur? The main way of transmission is through direct contact with the cells of the cervix. It means that a direct contact must be made for this virus to enter the squamous cells and glandular cells of the cervix. What is the main way of contact? Through sexual intercourse. Therefore, malignant diseases of the cervix are considered as sexually transmitted and infectious diseases. Cervical cancer is a sexually transmitted disease. Not that it is the only way. But the main way to transmit this disease is through sexual contact. Now that we know the location of the cervix, its physiology or its main work and histology,
and its diseases, Let’s see what risk factors are there? And how can we deal with those risk factors?
What are the risk factors? When we talk about risk factors, does it mean that if anyone is exposed to that main factor, they will develop cervical cancer? No. Many times, the immune system clears the virus from the body and prevents the development of malignant or premalignant changes. However, sometimes we have conditions where the virus cannot be cleared from the body. We need to identify those conditions. What are the risk factors?
A woman who initiates sexual activities at a very young age. Meaning, what age? 15 years, actually under 18 years old, starts to be sexually active. Now, if she engages in sexual contact, she should have an appropriate method of prevention. There are some preventive measures that reduce the chance of infection transmission. And these methods are known as barriers. An example that is available in the market is a condom. If someone intends to engage in intimacy, sexual health should be taken into consideration and maintained. Therefore, you should use an appropriate method.
There are also other individuals for whom risk factors are defined. Those whose immune system is weak. Why is the immune system of an individual weak? We mentioned that the HPV virus enters the body. It is also very common. In fact, the most common sexually transmitted virus is the human papillomavirus (HPV). If an individual’s immune system is strong, it can clear this virus. And it is expelled from the body without causing any problems. But if the person’s immune system is weakened for some reason, such as undergoing chemotherapy due to a disease like cancer of another organ, like the liver, kidney, or any other part of the body, or a woman who suffers from rheumatic diseases and is compelled to use corticosteroid compounds, she takes cortisone tablets, prednisolone. Well, the immune system of such an individual is weakened. This individual is at risk of developing premalignant and malignant changes if the virus enters their body. Other factors are also mentioned, such as smoking, which induces changes in the immune system and the cervical system, making it more likely for the virus to persist if it enters the cervix. And the persistence of the virus, especially its high-risk types, can lead to the progression of these changes to a premalignant state and eventually to a malignant form.
What are the risk factors again? An individual who engages in sexual contact with various people or whose sexual partner has contact with different individuals. Therefore, to mitigate this risk factor, we should avoid engaging in high-risk sexual behaviors. Among other risk factors mentioned are individuals who use hormonal contraceptives. We’re not saying you shouldn’t use them. These pills can induce changes in the cervix that may increase the likelihood of the virus persisting if it enters this area. And premalignant changes can occur. Therefore, if someone is using these pills, it is advisable for them to seek medical attention at healthcare centers and consult a doctor for an earlier diagnosis of the disease. Another factor includes women whose mothers used medication containing hormonal compounds during their pregnancy. Its name is Diethylstilbestrol (DES), and fortunately, it has been withdrawn from the pharmaceutical market since 1976.
However, it’s possible that a woman who is currently in her reproductive years had a mother who used it during pregnancy when she was in the fetal stage. It has been observed that the use of that drug can also lead to premalignant changes. Therefore, let’s review these risk factors:
Engaging in sexual activities at a young age, smoking, whether it’s cigarettes, cigars, or hookah, can pose risks to both the individual’s immune system and the local system present in the cervix. Engaging in sexual activities with multiple partners and not using appropriate preventive measures, having other sexual diseases; It has been seen that someone gets frequent infections, now these infections may show themselves in the form of discharge. And if these infections are not treated, the likelihood of the HPV virus persisting in the body and causing premalignant changes increases. Therefore, any infection, be it Chlamydia, gonorrhea, genital warts, or any other microorganism, should be treated to reduce the risk of the HPV virus persisting and causing premalignant changes. So contamination with those infections is one of the risk factors as well. If the patient’s mother has taken a compound called Diethylstilbestrol (DES) during pregnancy, it is also considered one of the risk factors. If a person with whom someone has sexual contact is suffering from cancer in their reproductive system, or is infected with this virus or has prominent lesions in their reproductive system, known as genital warts, appropriate treatment must be administered to prevent the development of premalignant conditions in the cervix. Now that we have identified these factors, let’s explore the available preventive measures.
Are there ways to prevent cervical cancer? The HPV virus takes time from the time it enters the body until it causes malignant lesions. We said it is an infectious disease. Therefore, it has a incubation period. Fortunately, it can take up to 15 years from the time the virus enters to cause cancer. So we can diagnose and treat it in the pre-malignant stages and prevent it from turning into cervical cancer.
What methods should we use? For all malignancies, there’s primary prevention, there’s secondary prevention, and there’s also tertiary prevention. What are these? What does primary prevention mean? Disease has a cause. It is not just a risk factor. It has an etiology. So let’s not let that virus enter our body. We know that it is the most common STD. Don’t be afraid of it. Perhaps, according to the statistics published in the world, 80 out of every 100 teenagers are infected with this virus. It’s okay. But not all of these cases have pre-malignant disease! To get the malignant type, the high-risk virus must enter and remain for more than 2 years, and the person’s immune system must be weak and unable to remove the virus.
So the primary prevention is to observe sexual hygiene. If we are going to have a healthy sex life, we should establish and observe our relations with regard to sexual hygiene. There is a vaccine available against this virus. However, it is not just a matter of getting the vaccine; we should also practice self-care and take precautions. In any case, adhering to hygiene principles in sexual relationships is the best way to prevent infection. There is also a vaccine available, and it is recommended to be administered to girls and boys at the ages of 11-12. If administered under the age of 15, two doses are sufficient, with a 6-month interval between them. You can get vaccinated up to the age of 26, and in boys, up to the age of 21. In individuals over 15 years old, it is administered in three doses.
At intervals of 0, one to two months later, and six months later. We mentioned initial prevention because it has a clear cause.
Now, what is secondary prevention?
If this virus enters the body, we can detect its footprint on the cervix.
What is the main method? Using a tool called a speculum, which is inserted into the vagina, we assess the cervix.
We detect the footprint of the HPV virus through a Pap smear. How do we perform this test?
We collect the secretions from the cervix on a slide or place them in a liquid solution, and then conduct the test.
Then, the laboratory doctor examines it under a microscope. It is recommended for all women to undergo a Pap smear test from the age of 21 to 65.
Pap smear has been performed since 1950 when Mr. Papanicolaou introduced it. We can detect the footprint of the HPV virus in it.
Every three years, every woman from the age of 21 to 65 should undergo a Pap smear.
Recently, we perform a dual test, meaning both Pap smear and HPV testing. It is done from the age of 30 to 65. It can be performed every three years or every five years if the results are normal. They set the age at 30 because we expect that when the HPV virus enters the body, it is cleared from the system, and the immune system is highly effective until the age of 30. For this reason, we recommend that a woman changes her lifestyle after the age of 30. She should consume an adequate amount of fruits and vegetables. She should strengthen her immune system so that it can clear the virus from her body. Exercise, maintaining a positive mindset, and having a good spirit are important for this. She should not be under stress. These are also considered preventive measures. So, for secondary prevention, we conduct Pap smear tests or dual tests.
Recently, according to clinical guidelines, it has been recommended to perform HPV testing alone from the age of 25 to 65, once every five years. And it is better if the HPV test is taken using the standard method. It is placed in an alcohol-based solution, and the laboratory doctor examines it under the microscope. There is no need to worry; we can treat the disease in the tertiary prevention stage. So, what is tertiary prevention? When we conduct a sample collection, and the results indicate the presence of pre-malignant changes in the cervix, or HSIL (High-Grade Squamous Intraepithelial Lesion), meaning high-grade changes in squamous or glandular cells. The ones that are created in the histology of the cervix.
We treat it with various methods. If it is detected at this stage, it can be treated. We can use various methods to destroy it, especially focusing on the transformation zone or T-zone, where the HPV virus lies. Either through heat-based methods or freezing methods, depending on the medical opinion.
After the Pap smear results indicate abnormalities, we use a device called a colposcope, which magnifies the changes and shows them to us. We take samples from the abnormal area because we do not treat with Pap smears; we only diagnose. A biopsy is performed, and using a tool, the abnormal area is identified, and now we can treat it. The treatment method in the T-zone can be destructive, or we can remove that area and perform excision. So, in cervical screening or tertiary prevention, we intervene in the precancerous area and prevent the patient from reaching the stage of cancer. Since this disease has an incubation period, conducting these screenings allow us to prevent it from progressing to cervical cancer.
Fortunately, in many countries, they have reached the point of saying that cervical cancer no longer exists. Because preventive measures are being taken. Cervical cancer is a disease that is preventable and treatable. So far, we have talked about premalignant diseases or pre-cancerous cervix. We reviewed the preventions together. Now let’s see what symptoms cervical cancer has? We mentioned that cervical cancer is one of the very common cancers. Fortunately, its prevalence has significantly decreased due to the screenings being conducted now. It means that we can diagnose it in the pre-cancerous stages. One of the risk factors is when a woman doesn’t go for screening and Pap smears. This is considered a risk factor. Every woman should go for Pap smears herself so that if she is to develop this disease, it can be diagnosed in the early stages. Unusual bleeding is one of the symptoms. This bleeding may be abnormal during menstruation, after intercourse, or between two periods, appearing as spotting. Or it could be a woman who has entered menopause and is experiencing bleeding afterward. These could be signs of cervical cancer. We do not expect a woman to experience bleeding one year after her last menstruation.
We should consider and examine such bleeding, and conduct a Pap smear. So, any woman facing abnormal bleeding should seek attention. Even sometimes if someone experiences excessively heavy bleeding during their period, passes clots, and has to wake up at night because of it, this might be a sign of malignant cervical diseases. Or it could be an infection with persistent discharge that doesn’t respond to various treatments. Well, it might be a disease in the cervix. Not that we want to scare you and say that every woman who gets infected has cervical cancer, no. The vaginal environment is connected to the outside through a pathway close to the anus, making it susceptible to infections. In any case, sexual contact can occur through this pathway. It can be prone to infection. However, when someone regularly experiences infections, uses various therapeutic medications, and doesn’t improve, necessary examinations should be conducted for them. This could be an early sign of cervical cancer.
Sometimes, we have patients who have bled so much that they become anemic. They may seek help from an internal medicine specialist due to heart palpitations. They undergo a blood test, see that they are significantly anemic, and realize the cause is bleeding. We don’t want to diagnose a patient at this stage. Blood clots form, their legs swell, and they develop DVT. These are advanced stages. The disease in the cervix has progressed, putting pressure on the lymph nodes, and they’ve developed a blood clot in their leg. And in some cases, through an examination tool, we realize that they have cervical cancer.
We don’t want to diagnose cancer at that stage. Or a woman who regularly experiences nausea and vomiting, we investigate and find that her kidneys are affected. The blood urea level has gone up. What has happened to her? Cervical cancer has put pressure on the part where urine enters the bladder (urethra),
preventing the discharge of urine. It has flowed back to the kidney, causing kidney problems. These stages are late for diagnosis, not that we cannot treat even in these stages. Therefore, any unusual symptoms a woman experiences, from bleeding to infections, pain, or pressure in the pelvis, urinary dysfunction, symptoms of kidney diseases or blood clots, could be signs of cervical cancer.
Once again, we emphasize that prevention is better than cure. If a person seeks medical attention before any lesions are found on the cervix, cervical cancer can be diagnosed in its early stages, making it a treatable condition. When we realize that cervical cancer is present through sample collection, Now we have to see what the clinical stage is. As a gynecological oncologist, I examine the patient. I usually go to the operating room for an examination. I examine under anesthesia. And we see how big the damage is. small or big? Has it spread from the cervix to its surroundings? For example, in the vagina? Or spread to the sides of the uterus? Like pelvic lymph nodes? In that case, we will understand the stage of the disease. Fortunately, if you visit in the early stages and the patient has a request for fertility,
we can remove this abnormal part and remove the cancerous uterus and even allow her to conceive. If we make a diagnosis in the early stages, there is the possibility of surgery while maintaining fertility. We only remove the unnatural part. provided that the disease is limited to the cervix and has not progressed.
Again, if we have symptoms and we have not noticed them in the prevention stage, i.e. pap smear and HPV test, and we have not treated the premalignant lesions, In the early stages, which is stage 1, we can remove this abnormal part and then allow the patient to become pregnant. So the surgical treatment of removal of the cervix itself, which is known as conization or tracletomy, can be done on the condition that there is no involvement in the lymph nodes. If the disease is in stage 2, that is, it leaves the cervix and reaches the vagina, and it is in its early stages, with a surgery performed by a gynecological oncologist, the uterus, that is, the body of the uterus, and its surrounding tissues, which we call parameters, are removed. And the lymph nodes are also removed and the patient definitely undergoes surgery.
If the patient is in a stage where surgery is not needed, other treatment methods such as radiotherapy are used. Doctors use radiation to eliminate cervical cancer. Therefore, we operate the patient up to a certain stage, and if it is more than that stage, the treatment will be with radiotherapy. Again, if the patient comes in very advanced stages, i.e. the patient has jaundice, she realizes that her cervical cancer has spread to the liver. We do not want to diagnose the disease at that stage. Methods such as chemotherapy are used to treat this disease in this stage. Therefore, we recommend early diagnosis of cervical cancer, as it is a preventable and treatable disease. Let’s know the prevention methods well. We know what the main factors are. And this virus also has low risk types. It means low risk of developing cervical cancer- And there are also dangerous types. Especially among the fifteen most dangerous types, types 16 and 18 are very dangerous. We should take them seriously, so that we can recognize and treat this disease in its pre-malignant stages. If the cancer is in its early stages, fertility preservation treatments can be performed. Because one of the most common ages of cervical cancer is between 35 and 39 years old, and it is for those who became sexually active very early. But one of the other common ages is 60 to 65 years. That is, patients who became sexually active from a common age. And we can perform early diagnosis and treatment in the pre-malignant stages.
Thank you very much.
