Let’s talk about HPV first…
The human papillomavirus (HPV) infects epithelial cells (surface cells) on the oral or genital mucous membranes and parts of the skin, such as the hands or feet. Any contact of those areas with a person who has the virus could lead to transmission. It’s common among sexually active adults and there are many different varieties of HPV. More often than not, the body is able to fight off the virus so that it’s eliminated over a few years. However, this sometimes isn’t the case, especially if a person’s immune system is compromised, or if they smoke. When the virus persists, it can cause problems such as warts, or potentially even cancer, such as cervical cancer. This is why it’s so important to go and have regular smear tests, in particular as these are incredibly effective at detecting pre cancerous disease, before it’s had a chance to develop.
But if you have an abnormal smear, please don’t panic, as it doesn’t necessarily mean there’s something wrong! Your doctor will also perform a test for HPV and if this is also positive, will refer you for a microscopic examination of your cervix, or colposcopy. Sometimes, that is all that is needed. But if you do need further treatment, then in the majority of cases this will stop any changes already there from developing into cancer. Please remember that cancer of the cervix in the Western World is thankfully rare because of the screening techniques we now use, so simply having HPV does not mean you have cancer, there is a huge and wide spectrum of possibility in between.
If your doctor decides that they need to remove abnormal cells, they’ll use one of the following techniques:
- cryotherapy, or freezing and eliminating the abnormal tissue
- a cone biopsy to remove part of the cervix
- a loop electrosurgical excision procedure (LEEP), which involves removing cells with a wire loop that carries an electrical charge
These procedures may affect your ability to conceive or reach full term in your pregnancy. This is because tissue removal from the cervix can change its structure. It may cause stenosis, or a narrowing of the opening of the cervix, which may present an obstacle to the sperm as they have to swim up the reproductive tract to reach the egg and fertilise it. Or it could present a problem during IUI or IVF if an embryo transfer is being attempted. The cervix may also weaken and whilst this will not cause infertility or difficulty becoming pregnant, it can lead to cervical insufficiency, which can cause your cervix to widen and thin before your pregnancy has come to term.
If you have had treatment to your cervix, your obstetrician may need to monitor this with extra ultrasounds, and may consider performing something called cervical cerclage, which is a tie around the cervix, to reduce the chance of cervical insufficiency.
Interestingly, some studies are finding that men who have sperm affected by HPV, could have consequences such as subfertility by affecting the sperm and its ability to fertilise an egg, or potentially contribute to miscarriage. However more research is needed to understand this in more detail.
Having the HPV vaccine before a person has sexual exposure, but even after, is now thought to significantly help prevent the development of cervical cancer, which has a strong association with HPV, and can subsequently help to preserve fertility. Barrier contraception is also important in terms of helping to prevent transmission of HPV, much like the other STDs, if you’re not trying for a baby.
Getting the HPV vaccine doesn’t completely eliminate your risk of getting cervical cancer, however. The vaccine protects against two strains that cause about 70 percent of cervical cancers, so even if you’re vaccinated, you can still contract other types, and you still need regular Pap screenings.
In general, HPV isn’t seen as a high risk to pregnancy and the potential for HPV transmission to a fetus during vaginal birth is low. However, you must always mention previous infection to your doctor, who may then decide to put you on some antivirals prior to delivery. Vaginal birth is usually encouraged over cesarean unless the patient has active disease. Again, this needs to be discussed with your doctor.
If you’ve been diagnosed with cervical cancer, there are many treatment options…
Cervical cancer treatment is very successful if you’re diagnosed in the early stages and the first thing to know is that the majority of treatment is very successful. The type of treatment used for cervical cancer depends on the stage at diagnosis. More advanced cancers usually require a combination of treatments that may involve surgery, chemo and radiotherapy.
Surgery for cervical cancer aims to remove all of the visible cancer. Sometimes nearby lymph nodes or other tissues are also removed, where the cancer has spread from the cervix. Your doctor may recommend surgery based on several factors. This includes how advanced your cancer is, whether you want to have children, and your overall health.
Cone biopsy removes a cone-shaped section of the cervix. It’s also called cone excision or cervical conization. It can be used to remove precancerous or cancerous cells. The cone shape maximizes the amount of tissue removed at the surface. Less tissue is removed below the surface.
Conization is performed using a cold knife or a loop electrosurgical excision (LEEP) procedure. LEEP uses electrical current to cut through and cauterize cervical tissue.
After conization, the abnormal cells are sent to a specialist for analysis. The procedure can be both a diagnostic technique and a treatment. When there is no cancer at the edge of the cone-shaped section that was removed, further treatment may not be necessary.
Hysterectomy is the surgical removal of the uterus and cervix. It greatly reduces the risk of recurrence when compared to more localized surgery. However, a woman cannot have children after a hysterectomy. It can be performed using three different ways: abdominal, vaginal and laparoscopic (or keyhole).
Trachylectomy is an alternative to a hysterectomy. The cervix and upper part of the vagina are removed. The uterus is left in place. It’s connected to the vagina with an artificial opening. Trachelectomies allow women to maintain the ability to have children. However, there is a high rate of miscarriage.
If radiation treatment is needed, there could be damage sustained to the vagina or ovaries and this can impact future fertility. This is why something called ovarian transposition, or hitching and suturing the ovaries to the pelvic side wall, is important before radiation, to try and preserve as much healthy tissue as possible for women who want o use their own eggs to become pregnant later.
Chemotherapy uses drugs to kill cancer cells. Drugs may be administered before surgery to shrink tumors. They can also be used afterwards to get rid of remaining microscopic cancerous cells.
What about preserving fertility….
Many women with cervical cancer are in their reproductive years, and so preserving fertility and understanding possible consequences to any pregnancy is crucially important.
Most women are advised to wait 6 to 12 months after conization or trachelectomy before attempting to become pregnant to allow the tissue to heal fully. But there are still risks to any possible pregnancy, and your obstetrician will help to safeguard you against these as much as possible.
Cervical insufficiency occurs when the cervix opens or thins earlier than normal during pregnancy. This can lead to miscarriage or preterm delivery (when delivery occurs before 37 weeks of pregnancy). Women who have had cervical conization or radical trachelectomy may be at an increased risk of cervical insufficiency. For these reasons, women who undergo treatment for cervical cancer are followed closely during pregnancy. This generally involves regular monitoring of the length and opening (dilation) of the cervix. Research has shown that risk of premature delivery is related to the proportion of tissue taken.
Bu the figures regarding birth outcomes offer some reassurance. According to the latest research regarding vaginal trachylectomy, over 250 pregnancies resulting in over 100 live births have been reported up until 2009. Of those attempting to conceive, up to 79% were able to conceive. The rate of miscarriage in the 1st trimester was similar to the normal population but there was an increase to 8–10% in the risk of 2nd trimester miscarriage and the risk of significant premature delivery was 12%.
Where it is important to preserve fertility in a woman who has been diagnosed with cervical cancer, if she either hasn’t had children or is planning on having more in the future, there are several options for how to do this. The most important thing is to recognize the need to see a fertility specialist about this and to be referred on time so that the crucial opportunity is not missed to save eggs and ovarian tissue before it is damaged or removed during any cancer treatment. Fertility preservation options include:
- egg freezing prior to treatment, but it may delay treatment and may be complicated if the cancer is hormone sensitive, meaning any drugs given to stimulate the ovaries could have an impact on the cancer
- embryo creation and freezing prior to treatment for cancer, where eggs are collected and fertilized with sperm, there is a higher chance of success with this but again, could be affected by similar problems as the above
- removing and freezing ovarian tissue for reimplantation later after cancer treatment has been completed. This is a fairly novel technique that some units are offering and though successful pregnancies are beginning to be reported with this, it remains to be seen how successful it is.
Despite recent advances and improving success rates with egg and embryo preservation, there are no guarantees that these methods will result in a successful pregnancy for any individual, and ultimately egg donation and surrogacy, if the woman has had a hysterectomy, may be needed.
Being diagnosed with cancer is awful and seeking help from a counselor to offer emotional support and help you to focus on a plan, is absolutely vital. Thankfully, there are also many support groups and charities out there who campaign hard to raise awareness of cervical disease and are an incredible source of help for many. They include The Eve Appeal and Jo’s Cervical Cancer Trust. When you have had time to consider what you wish to do, then it’s important to go and see a fertility specialist, if you want to keep having children an option for yourself, who can then best guide you and liaise with your oncologist regarding the best fertility preservation option for you. There are many options, so finding the one that suits you best is vitally important. Being armed with some awareness on this subject will go a long way in helping you understand your options to be able to make empowered decisions.
