Cervical cancer: Tips to aid early diagnosis

Key takeaways

• Abnormal vaginal bleeding is a common presentation in primary care, an appropriate examination and safety netting is essential to avoid a late stage diagnosis.??

• Irregular bleeding within the first 6 months is common in patients using hormonal contraception or HRT; however other causes should not be ruled out.??

• For patients presenting with abnormal vaginal bleeding, offer a speculum examination, especially if symptoms are persistent. Ask about any associated symptoms as well.?

• Investigate persistent abnormal bleeding: after 3 months for hormonal contraception users, or beyond 6 months of starting HRT, or 3 months after a dose change.?

Cervical cancer is the 14th most common cancer in the UK (2017-2019) with the highest incidence rates being in individuals aged 30-34 (CRUK).?

Cervical screening detects most cases of cervical cancers and HPV related changes, but declining participation highlights the need for clinicians to recognise key signs and symptoms of cervical cancer. ?

The most common symptom is vaginal bleeding at times other than a menstrual period, this includes:?

• Intermenstrual bleeding?

• Post-coital bleeding?

• Post-menopausal bleeding?

• Haematuria?

• Irregular periods or a change to the pattern of menstruation?

Other symptoms can include dyspareunia, changes to vaginal discharge, abdominal or pelvic pain, UTI’s, a high white cell count or low haemoglobin, leg swelling and changes to the bladder or bowels.??

Pitfalls: Abnormal vaginal bleeding is common

Abnormal vaginal bleeding is a common symptom in many benign conditions which can easily contribute to the delayed diagnosis of cervical cancer.??

• Patients may experience abnormal vaginal bleeding for months and believe it is normal.?

• Some patients may seek only reassurance, but if clinicians fail to consider cervical cancer as a potential diagnosis and provide appropriate safety netting, these patients may not return if symptoms persist.?

• Remote consultations can hinder early diagnosis.??

• Irregular bleeding is common in patients using hormonal contraception or HRT; however other causes should not be ruled out.??

A cervical smear test is not a diagnostic test and should not be used if symptoms are present, patients should be examined and referred if there are any concerns.? ?

Helpful hints: Assessment and safety netting

The primary risk factor for cervical cancer is HPV, with additional risks including age, smoking, early sexual activity (<18), young motherhood (<17), long-term oral contraception use, multiple sexual partners and immunosuppression. Assess patients’ HPV vaccination status and participation in cervical screening.??

• Offer a speculum examination for persistent abnormal vaginal bleeding, ask about related symptoms, and use vaginal swabs to help identify cervical lesions or diagnose other causes accurately.??

• NICE recommends a bimanual and speculum examination in cases of menorrhagia with associated symptoms such as persisting intermenstrual bleeding, pelvic pain and/or pressure symptoms (except in those who have never been sexually active).??

• In the UK, 47 women under the age of 25 are diagnosed with cervical cancer each year, so a speculum should still be considered in younger patients if there are clinical concerns.?

• Investigate persistent abnormal bleeding: after 3 months for hormonal contraception users (offer a speculum examination and a bimanual if there are associated symptoms) or beyond 6 months of starting HRT or 3 months after a dose or mode change.??

• Self-swabs may be considered in patients to exclude sexually transmitted or vaginal infections if there is a reluctance for examination. It is important to advise patients to return for further assessment if symptoms persist, even if the swabs are negative.?

Practice takeaway?

Access GatewayC’s course on cervical cancer for more practical points to aid the early diagnosis of cervical cancer.?

Find out more:?

• Cervical screening course | GatewayC
• Cervical cancer statistics | Cancer Research UK

• Management of unscheduled bleeding in women using hormonal contraception | FRSH and RCOG
• Cervical cancer | BMJ Best practice

• Menorrhagia | NICE CKS