Information for Women: The cervical smear

Contents

This brochure is published by the Information department of the Dutch Anti-Cancer Campaign/ KWF

January 1997

If this brochure is more than 3 years old, ask whether there is a newer version. The brochure is printed on environmentally friendly paper.

©KWF 1997

Who is this brochure for

Each year in the Netherlands, cervical cancer is diagnosed in about 750 women.
Cervical cancer is a sort of cancer which can be detected very early using a simple test. That test is the cervical smear. Whenever cervical cancer is detected and treated in a woman at a very early stage, then the chance of being cured is almost 100 per cent.

This brochure is intended for women who want to know more about the cervical smear test. The following questions are discussed:

  • What is cervical cancer and what is known about the causes?
  • What is a cervical smear and who is tested?
  • How is a cervical smear test done?
  • What is the significance of the classification given to the test result?
  • How is a pre-stage of cervical cancer treated?

If you have any other questions about the cervical smear, then you should discuss them with your general practitioner. You can also contact one of the information centres listed in the back of this brochure.

What is cancer

Each year some 61,000 Dutch people are diagnosed with cancer. There are more than one hundred different sorts of cancer. Each sort of cancer is a different disease, but they all have one thing in common: there is an unlimited division of abnormal cells. In time this threatens our health.

Cell division

The body of an adult consists of billions of cells. These cells go old or become damaged and then have to be replaced. Children need new cells to grow. Per hour our body makes millions of cells. New cells arise from the division of cells, so that one cell becomes two new ones. If temporarily somewhere in our body no new cells are needed, then cell division ceases. Our body regulates that itself.

Cancer

Cancer cells show all kinds of abnormalities. These result amongst other things in our body being unable to stop the division of cancer cells. More and more abnormal cells are produced. Over a period of time a malignant tumour will develop. Other abnormalities in the cancer cells allow the tumour to be able to grow within surrounding tissue. There it causes damage and disturbs the functioning of our body. Cancer cells can also break loose from the tumour and using lymph fluid and/or blood for transportation, can finish up in other parts of our body. There the cells keep dividing. This causes new tumours : secondaries. The medical word for these is : metastases. Blood cells and lymph cells can also change into cancer cells. The large numbers of abnormal cells upsets the working of the blood and/or lymph. An example of cancer of the blood cells is leukaemia; an example of cancer of the lymph system is Hodgkin’s disease.

Benign tumours

There are also benign tumours. In that case there is no cancer. A benign tumour does not grow within surrounding tissues and there are no secondaries. An example of a benign tumour is a fat tumour (the medical name is lipoma). A benign tumour can however also cause symptoms that make treatment necessary.

The female sexual organs

The female sexual organs include the womb (uterus), the ovaries and the Fallopian tubes. These organs lie in the lowest part of the abdomen (the lower pelvis). The womb is shaped like an upside -down pear. On either side of it lie the ovaries and the Fallopian tubes. The Fallopian tubes link the ovaries and the womb. These organs are held in place in the abdomen by supporting tissue.

The womb

The womb consist of the main body of the womb and the neck of the womb. The neck of the womb forms the link between the body of the womb and the vagina; the cervix lies at the outer end of the neck of the womb.

The body of the womb is lined inside with mucous membrane, which is broken down monthly – during menstruation (period).

The neck of the womb and the cervix are also lined with mucous membrane. This is not broken down during the menstrual period.

The mucous membrane in the neck of womb consists of a different type of cells than the mucous membrane in the cervix. At the place where these two sorts of cells meet there is a boundary.

Illustration Female sexual organs

  1. Fallopian tube
  2. ovary
  3. main body of womb
  4. neck of the womb
  5. cervix
  6. vagina

Cervical cancer

Cervical cancer occurs usually in cells in the mucous membrane on the boundary of the neck of the womb and the cervix. This generally takes place very slowly: the time between the first abnormal cell and the moment that cervical cancer actually occurs can be 10 to 15 years.

To start with there are a few abnormal cells. At this point in time there is no cancer present. The cells are completely harmless. Moreover they often disappear by themselves.

If the number of abnormal cells increases, then after a while a pre-stage of cervical cancer arises. The disorder is at this stage very limited and can with a simple method of treatment be treated effectively.

If this pre-stage remains untreated, then cervical cancer is the consequence. To begin with the cancer cells are in a so-called initial stage. After treatment the chance of a cure at such an initial stage is almost 100 per cent.

Even if the cervical cancer has progressed further, there is after treatment a good chance of a cure. This does however reduce the more that the disease has progressed and spread.

Cervical cancer occurs in women of all ages, but mostly in women between 35 to 45 years old. Nowadays this sort of cancer is being found at somewhat younger ages than before.

Causes

For each sort of cancer, certain circumstances can increase the risk of the disease.

A virus, the human papilloma virus, often plays a role in the occurrence of cervical cancer. This virus is transmitted through sexual intercourse. The more varied the sexual contacts, the greater the chance of transmitting the virus.

On the whole the human immune system will see off these sorts of viruses. Sometimes the virus still gets through. The virus can then cause changes to occur in the cells of the cervix. In a number of cases this leads to cervical cancer.

Whenever a woman has cervical cancer, this should not lead automatically to the conclusion that she or her partner has (had) by definition a variety of sexual contacts.

Cervical cancer seems to occur more frequently among women who smoke than among women who don’t smoke. Smoking affects the immune system whereby the body is more susceptible to disease agents.

Research is still going on into the use of the pill and the possible risk of cervical cancer. The results up till now give no reason for advising against the use of the pill because of a possible risk of cervical cancer.

Just like the majority of sorts of cancer, cervical cancer is not hereditary. Nor is cervical cancer infectious.

There is, therefore, no risk that the partner would acquire some sort of cancer through sexual intercourse.

Symptoms

Changes in the cells of the neck of the womb do not lead in the first instance to symptoms. The first sign that a woman would notice is an unusual bloody discharge. It does not always have to be real bleeding. If there is only a small amount of blood lost this produces a brownish discharge. Sometimes a woman will only notice a few brownish streaks.

In all cases it concerns blood loss outside the normal menstrual period:

  • Thus blood loss can occur during or shortly after sexual intercourse. This is called contact bleeding. Any tumour present on the cervix can bleed as a result of sexual intercourse.

Nevertheless contact bleeding can also occur in women using the pill without any abnormalities being present.

  • Bleeding or a bloody discharge can also occur between two menstrual periods.
  • Women who have already experienced the menopause can also suddenly be confronted with bleeding. This is sometimes confused with a sudden reappearance of menstruation. If, however, a woman has not menstruated for about a year, then such bleeding is not considered as normal menstruation.

For all unusual bleeding, investigation by the general practitioner is necessary to find out precisely what is happening. The general practitioner will perform an internal examination and take a cervical smear.

Early detection

Using a cervical smear test changes in the neck of the womb can be detected before they give rise to symptoms. This makes the cervical smear a suitable method for the early detection of cervical cancer.

General screening programme

Until recently women between 35 and 55 years old were invited once every three years to have a cervical smear test carried out by their general practitioner.

Scientific research has revealed that the cervical smear test is most useful between the ages of 30 and 60. This research also showed that most of the abnormalities were detected in time using a cervical smear test every five years. Of course, women with symptoms should have the test done earlier.

New developments

Within in the framework of scientific research a test has been developed which shows up the virus in a smear. At present, research is still on-going as to whether women in whom this virus is found should be monitored more frequently. Also research will test whether women without the virus can be monitored less often.

This test is still not yet suitable for use on a large scale, such as screening large populations.

The cervical smear

Before the test is taken, your general practitioner will ask a few questions, like:

  • Do you use a contraceptive? If yes, which one (pill, condom, IUD. Dutch cap, contraceptive injection)?
  • Do you still have regular periods? If yes, when was the last menstruation?
  • Do you have children? If yes, how many?
  • Are you bothered by any unusual loss of blood from the vagina:
  • between menstrual periods;
  • during or after sexual intercourse;
  • if you have had not had a menstrual period for more than a year?

Even a small amount of blood loss – sometimes no more than a brownish discharge – are worth mentioning.

All these issues play a role in the assessment of the cervical smear. That is why you are asked about them.

The test

To have a cervical smear taken you have to lie on an examination table. You keep your legs bent and rest your feet on the table. Some doctors have an examination table with special leg supports.

To allow the cervix to be seen properly it is necessary to open the vagina a little wider. That is done using a metal or plastic instrument called a speculum. It looks a bit like a duck’s bill. First the speculum is held under a lukewarm tap so that it is not so cold to bring it in. Thereafter the instrument is carefully inserted, still closed, into the vagina (A). Then the speculum is slowly opened. In this way the cervix can be easily seen.

It is now possible to take the cervical smear. This is usually done using a wooden spatula, sometimes a little brush is used. The point of the spatula is placed in the cervix and fully rotated once. In this way some mucous with cells is scraped from the cervix. (B)

The mucous is smeared on a glass plate (C) Hence the term ‘smear’. It is then almost always sprayed with a fluid, called fixative, to preserve the cervical smear better; this is called fixation.

The test is then finished. The speculum is closed and removed from the vagina. (D)

On the whole having a cervical smear taken is painless. It is handy to take the following points into account:

  • The test is easier to perform if the bladder is empty and you relax your abdomen.
  • Removing the mucous can create a somewhat sickening sensation.
  • If you have not (or rarely) had sexual intercourse, then you should state so when having this test. Then a smaller speculum will be used. In this way the test can also be carried out painlessly in women with a somewhat narrower vagina.
  • Sometime there may be a little blood loss afterwards. This is however of no significance.

Laboratory

The glass slide with the cervical smear is sent together with your details to a laboratory. There it is examined under a microscope. The cells in the cervical smear show whether the cervix is healthy or whether there are abnormalities. If abnormal cells are found, it does not always mean that there is cancer. A short-lived infection can also produce abnormal cells.

In general it is several weeks before the result is known. Ask your doctor, when the cervical smear is done, about when you can telephone for the result.

Repeat cervical smear

Sometimes a cervical smear has to be repeated. That does not mean automatically that something serious has been found. It is also possible that the first smear was not done properly. For example, if there are too few cells in the mucous smear, then the smear cannot be assessed properly.

Also if there is a bit of blood in the smear, then a second smear is sometimes necessary. It is therefore better not to have a smear test done if you are having a period.

If a smear test needs to be repeated within a short period of time, you can always ask why it is needed.

The result

Making and assessing a cervical smear is a investigative method which was first applied by Dr Papanicolaou. The cervical smear test is also called the PAP test after him.

The method of assessment which is used nowadays to judge a cervical smear is called the KOPAC-B

classification. This KOPAC-B classification is used in the laboratory to indicate in detail the changes in the cells of the cervix. Each letter of the KOPAC-B classification stands for a particular aspect of the cervical smear.Thus the letter ‘P’ stands for squamous cell epithelium, a type of cell that occurs in the smear. The letter ‘O’ stands for inflammation.

In the result of the smear the changes in the cells are indicated by the number 1 to 9.

Number 1 indicates that no abnormal cells were found. The higher the number the greater the number of abnormalities found in the cells of the smear. As was stated before, this does not always have to mean that there is cancer. Abnormalities can, for instance, be caused by an inflammation or a not yet cancerous pre-stage.

Follow-up advice

With the result, follow-up advice is also given about having another smear test or the patient is referred to a gynaecologist for further investigation:

KOPAC-P1 – A repeat smear in five years

KOPAC-P2. 3 and 4 – With these results a repeat smear is recommended after six months:

If this repeat smear is again normal, then a smear will then be taken again after a year.

If this repeat smear is abnormal, then a referral to a gynaecologist for further investigation follows.

KOPAC-P5,6,7,8 and 9 – With these results investigation and (any) treatment by a gynaecologist is urgently needed. Usually tissue investigations will be needed to establish the diagnosis.

Costs

If a cervical smear is necessary because you have certain symptoms then the test will be paid for by the national health insurance fund. Reimbursement by a private medical insurance company will depend on the conditions of your insurance.

For women who have a cervical smear taken by their general practitioner within the scope of the national screening programme, then no costs are involved in that test. The costs are borne by the national government (AWBZ).

Whenever you have no symptoms, are younger or older than the age limits set for the national screening programme and still want to have a cervical smear taken, then you have to reckon on paying the costs yourself.

Since changes are regularly being made to the system of reimbursement it is advisable to get the latest information from your insurance company.

Treatment of an initial stage

Whenever the laboratory results show that an initial stage of cancer may possibly be present, further investigation by a gynaecologist is needed. This specialist always starts by carrying out an internal examination. He feels whether there are any abnormalities in the shape and size of the organs in the lower pelvis.

With the aid of a colposcope, a special sort of high magnification microscope, the specialist will examine the inside of the womb. This is called a colposcopic examination.

If an initial stage of cancer is detected, then the specialist can carry out a local treatment. There are a number of ways to treat an initial stage of cancer.

Cryosurgery

This method destroys the affected tissue by freezing it. An anaesthetic is not necessary.No admission to hospital is needed for this treatment.

Laser treatment

Nowadays an initial stage of cervical cancer is sometimes treated using laser light. This light destroys the affected tissue. Anaesthetic is not needed, nor is a stay in hospital.

Local excision

A local excision is a treatment in which only the affected tissue is removed. The treatment is usually carried out as an outpatient procedure; local anaesthetic can be needed.

The tissue which on colposcopic examination appeared to be suspect is scraped off the surface of the cervix during a local excision. You could compare this to peeling the skin.

The doctor uses a diathermy loop. This electrically heated wire also cauterises the small blood vessels of this very superficial wound.

Conisation

This treatment consists of a small operation in which the affected tissue is removed; the uppermost portion of the cervix is cut away. The section removed is shaped like a cone. The womb remains intact. For this small operation the patient must spent a couple of days in hospital. The operation is performed under general anaesthetic or by using epidural anaesthesia to numb the lower body.

Repeat smear

Patients who have undergone one of the above treatments must be monitored annually using a cervical smear test.

Removal of the womb

Sometimes the gynaecologist will suggest that the patient with an early stage of cancer should have the entire womb removed. This may be the case for a woman who is sure she no longer wants children and who moreover is bothered by symptoms, such as excessive blood loss during menstruation.

The brochure Cervical Cancer is available from the Dutch Anti-Cancer Campaign. In the chapter on treatment, the operation to remove the womb is discussed.

Less risk of cancer

By having a cervical smear taken regularly, any changes can possibly be detected earlier. Early detection of cervical cancer increases the chance of a cure. It is certainly just as important to limit your risk of cancer in general as much as possible.

How you can help yourself with prevention is set out in the first six recommendations of the ‘European Code against Cancer’. The last four recommendations summarise how you can help to detect cancer early.

The European Code against Cancer

The recommendations below are good for your health. Moreover they help limit the risk of a number of forms of cancer.

  1. Don’t smoke. Smokers, stop as soon as possible. Tobacco smoke is also damaging for non-smokers, so don’t smoke in their presence. Non-smokers, don’t start.
  2. Drink beer, wine or other alcoholic beverages only in moderation.
  3. Eat sufficient fruit and vegetables every day. Eat high fibre (grain) products regularly.
  4. Avoid being overweight, make sure you have enough physical activity and use lower fat products.
  5. Avoid too much sun radiation . Do not allow children to get sunburnt.
  6. Apply the regulations which are aimed at preventing exposure to carcinogenic substances or which are aimed at limiting the risks.

The earlier that cancer is detected the better it can be treated

  1. Always go to see your doctor (even if you have no pain):– when an abcess or wound will not heal (also when it’s in your mouth)
    – if a birthmark or mole changes size, shape or colour;
    – if you have unusual loss of blood;
    – when you discover a lump or swelling.
  2. Go to see your doctor when symptoms persist such as:– hoarseness or a cough
    – unexplainable loss of weight
    – change in bowel movement or when urinating.

    For women :

  3. Have a cervical smear taken regularly. When you are called up for a national screening programme take part in the screening.
  4. Check your own breasts every month. When you are over 50 take part in the national breast cancer screening programme.

The European Code against Cancer has been drawn up by cancer experts from the fifteen countries of the European Union (EU). This forms part of the EU campaign programme ‘Europe against Cancer’. The aim of this campaign is to reduce the expected increase in deaths from cancer in the EU countries.

Do you have any questions?

If you have any questions after reading this brochure, don’t just keep them to yourself. Personal questions are best discussed with your general practitioner. If you have questions about cancer that are more general, or you want to talk to someone else about your questions before you visit your doctor, then you can also ask for help at the Information Centre of the Dutch Anti-Cancer Campaign and at the Integrated Cancer Centres.

Information Centre Dutch Anti-Cancer Campaign

The Information Centre of the Dutch Anti-Cancer Campaign is situated at:

Sophialaan 8, 1075 BR Amsterdam.

In the Information Centre someone is available to discuss your questions. The centre is open from Monday to Friday between 9.00 and 17.00 hrs. For information in brief you can just walk in. If however you wish to discuss matters personally at length, then it’s better to make an appointment. You can also write or phone. There is a free Help and Information line 0800 – 022 66 22 (on working days between 10.00 – 12.30 hrs and 13.30 – 16.00 hrs. Your call will be received on a telephone answering system. By pressing or dialling numbers on your phone you can choose to talk to someone or order a folder. Orders from organisations and institutions can only be handled in writing!

Suggestions about the contents of this brochure can be made in writing to the Information Centre of the Dutch Anti-Cancer Campaign.

Integrated Cancer Centres

Information about cancer is also given by the Integrated Cancer Centres. Besides information for social workers, these centres also supply information to patients and the public.

Information Dutch Anti-Cancer Campaign

Information about cancer and anti-cancer by means of:

folders brochures documentation video programmes training
free help and information line for personal help and information
0800 022 66 22
The Information centre of the Dutch Anti-Cancer Campaign is open from 9am to 5pm
Sophialaan 8, 1075 BR Amsterdam
Extended visits, preferably by appointment