Cervical cancer

Cervical cancer begins when abnormal cells in the lining of the cervix grow uncontrollably.  Cancer most commonly starts in the area of the cervix called the transformation zone. It may then spread to tissues around the cervix, such as the vagina, or to other parts of the body, such as the lymph nodes, lungs or liver.

There are 2 main types of cervical cancer:

• squamous cell carcinoma (SCC) – the most common type (about 6 out of 10 cases), starts in the squamous cells of the cervix
• adenocarcinoma – a less common type (about 3 out of 10 cases), starts in the glandular cells of the cervix. Adenocarcinoma is more difficult to diagnose because it occurs higher up in the cervix and the abnormal glandular cells are harder to find.

A small number of cervical cancers (less than 1 in 20 cases) feature both squamous cells and glandular cells. These cancers are known as adenosquamous carcinomas or mixed carcinomas. Other rarer types of cancer that can start in the cervix include small cell carcinoma, clear cell adenocarcinoma and cervical sarcoma.

Anyone with a cervix can get cervical cancer – women, transgender men and people with an intersex variation. Each year in Australia, about 960 women are diagnosed with cervical cancer.

Cervical cancer is most commonly diagnosed over the age of 30 years. More than half of all cervical cancer cases occur in those aged 30–49 years, but it can occur at any age.

Diagnoses of cervical cancer in Australia reduced significantly after a national screening program was introduced in the 1990s. The introduction of a national human papillomavirus (HPV) vaccination program in 2007 and improvements to the screening program in 2017 are expected to further reduce rates of cervical cancer.

Precancerous cervical cell changes usually have no symptoms. The only way to know if there are abnormal cells in the cervix that may develop into cancer is to have a cervical screening test. Cervical cancer symptoms may include:

• vaginal bleeding between periods, after menopause, or during or after sexual intercourse
• pelvic pain
• pain during sexual intercourse
• a change to your usual vaginal discharge (e.g. there may be more discharge or it may have a strong or unusual smell or colour).

Any of these symptoms can happen for other reasons, but it is best to rule out cervical cancer. See your general practitioner (GP) if you are worried or the symptoms are ongoing. This is important for anyone with a cervix – whether heterosexual, lesbian, bisexual, transgender or someone with an intersex variation – even if you are up to date with cervical screening tests.

Sometimes the squamous cells and glandular cells in the cervix start to change, and appear abnormal when viewed under a microscope. These early cervical cell changes may be precancerous. This means there is an area of abnormal tissue (a lesion) that is not cancer, but may lead to cancer.

Some people with precancerous changes of the cervix will develop cervical cancer, so it is important to investigate any cervical cell changes.

How precancerous cell changes start

Precancerous cervical cell changes are caused by some types of the human papillomavirus  (HPV). The latest evidence suggests that all squamous cell cancers and about 9 out of 10 adenocarcinomas are caused by HPV.

HPV and cervical cell changes don’t usually cause symptoms but can be found during a routine cervical screening test.

There are 2 main types of cervical cells that can have precancerous changes – squamous cells and glandular cells.

Abnormal squamous cells – Previously called cervical intraepithelial neoplasia (CIN), these are now called squamous intraepithelial lesions (SIL). They can be classified as either low grade (LSIL) or high grade (HSIL), depending on how abnormal the cells are and how deep they are
in the surface of the cervix.

LSIL usually disappear without treatment, while HSIL can be precancerous. High-grade
abnormalities have the potential to develop into early cervical cancer if they are not found and treated.

Abnormal glandular cells – High-grade precancer in glandular cells is called adenocarcinoma
in situ (AIS or ACIS). AIS is not cancer, but needs treatment to reduce the chance that it develops into adenocarcinoma.

Treating cervical cell changes

Finding and treating precancerous cervical cell changes will prevent them developing into cervical cancer.

Almost all cases of cervical cancer are caused by an infection with the human papillomavirus (HPV). 

Infection with HPV – HPV is the name for a group of viruses. Infection with HPV is common. It affects the surface of different areas of the body, such as the cervix, vagina and skin. Some types of HPV cause cancer, while others can cause common warts on the hands and feet.

There are more than 100 different types of HPV, including over 40 types that can infect the genitals. Genital HPV is usually spread during close contact with genital skin during sexual activity. This includes penetrative sex as well as oral sex and other forms of sexual activity (e.g. using sex toys). Using condoms or dental dams offers some protection against HPV.

About 4 out of 5 people will become infected with at least one type of genital HPV at some point in their lifetime. Most people will not know they have HPV because it doesn’t cause symptoms. In most people, the virus is cleared quickly by the immune system and no
treatment is needed. If the infection doesn’t go away, there’s an increased risk of developing changes in the cervix. These changes usually develop slowly over many years.

Fourteen types of genital HPV are known to cause cervical cancer. The cervical screening test is used to detect most of these types of HPV and the precancerous cell changes caused by the virus. There is also a vaccine that protects people from some types of HPV.

National HPV vaccination program

Vaccination can prevent infection with HPV. The most common HPV vaccine used in Australia protects against 7 high-risk types of HPV known to cause about 9 out of 10 cervical cancers, as well as 2 types of HPV that cause most genital warts. The vaccine also offers some protection against less common cancers linked with HPV, including vaginal, vulvar and anal cancers.

Under the national HPV vaccination program, free vaccines are provided at school for all children aged 12–13. If you weren’t vaccinated at school, and are aged 45 years or under, ask your doctor if you may benefit from having the vaccine.

Even if you have been vaccinated against HPV, you will need regular screening tests as the HPV vaccine does not protect against all types of HPV.

The HPV vaccine does not treat cervical cancer or precancerous cell changes. For more information, visit HPV Vaccine.

Other factors that may increase the risk of developing cervical cancer include:

• Smoking and passive smoking – Chemicals in tobacco can damage the cells of the cervix, making it harder for the body to clear the HPV infection.
• Using oral contraceptives (the pill) for a long time – Research has shown that taking the pill for 5 years or more increases the risk of developing cervical cancer in people with HPV. The reason for this is unclear, and the risk is small. However, the pill can help protect against other types of cancer, such as cancer of the uterus and ovarian cancer. Talk to your doctor if you are concerned.
• Having a weakened immune system – The immune system helps rid the body of HPV. In some people, a weakened immune system can increase the risk of developing cervical cancer, so more frequent cervical screening tests may be needed. This includes people with human immunodeficiency virus (HIV) and those who have had an organ transplant.

Screening is organised testing to find precancer before it develops into cancer, as well as early cancers before symptoms appear. The cervical screening test – which has replaced the Pap test – finds cancer-causing types of HPV in cell samples taken from the cervix.

The National Cervical Screening Program recommends that women start cervical screening at age 25 and then have a test every 5 years. A final test is recommended between ages 70 and 74. All people with a cervix need regular screening. There are 2 ways to collect cells for a cervical screening test. In most cases, you can choose the way you prefer.

Health provider collected – During the test, a doctor or nurse gently inserts an instrument (called a speculum) into the vagina to widen the vaginal walls and get a clearer view of the cervix. They will then use a brush or spatula to remove some cells from the cervix. This can feel slightly uncomfortable, but usually takes only 1–2 minutes. The cell sample is then placed in a container of liquid and sent to a laboratory to check for HPV. If HPV is found, a specialist doctor called a pathologist will do an additional test on the sample to check for cell abnormalities. This is called liquid-based cytology (LBC).

Self-collected – This is done in a private space (e.g. a bathroom) in a health clinic. A health care provider will give you a self-collection swab and explain how to collect your own cell sample. Or, if you prefer, the provider can assist you to collect the sample without using a speculum. Self-collection is only available to people who do not have any signs or symptoms of cancer. Self-collected samples are not suitable for liquid-based cytology, so if HPV is detected, you may be asked to return to have a health provider collect a second sample or be referred for a colposcopy.

The test results are used to predict your level of risk for significant cervical changes. If the results show:

• a higher risk – you will be referred for a colposcopy
• an intermediate risk – you will be monitored with a follow-up screening test in 12 months
• a low risk (no HPV detected) – you will be due for your next cervical screening test in 5 years.

For more information, call Cancer Council 13 11 20 or visit Cervical Screening.

Your GP will arrange the first tests to assess your symptoms. If these tests do not rule out cancer, you will usually be referred to a specialist, who will arrange further tests.

If cervical cancer is diagnosed, the specialist will consider treatment options. Often these will be discussed with other health professionals at what is known as a multidisciplinary team (MDT) meeting. During and after treatment, you will see a range of health professionals who specialise in different aspects of your care.

Health professionals you may see

gynaecologist – specialises in diseases of the female reproductive system; may diagnose  cervical cancer and then refer you to a gynaecological oncologist

gynaecological oncologist – specialises in cancers of the female reproductive system; diagnoses and performs surgery for these cancers, including cervical cancer

radiation oncologist – treats cancer by prescribing and overseeing a course of radiation therapy

medical oncologist – treats cancer with drug therapies such as chemotherapy and targeted therapy

radiologist – analyses x-rays and scans; an interventional radiologist may also perform a biopsy under ultrasound or CT guidance, and deliver some treatments

radiation therapist – plans and delivers radiation therapy

cancer care coordinator – coordinates your care, liaises with MDT members, and supports you and your family throughout treatment; care may also be coordinated by a clinical nurse consultant (CNC) or clinical nurse specialist (CNS)

nurse or nurse practitioner – administers drugs and provides care, information and support throughout treatment; a nurse practitioner works in an advanced nursing role and may prescribe some medicines and tests

dietitian – helps with nutrition concerns and recommends changes to diet during treatment and recovery

social worker, psychologist – link you to support services; help with emotional and practical problems associated with cancer and treatment

women’s health physiotherapist – treats physical problems associated with treatment for
gynaecological cancers and lymphoedema

A colposcopy is a way of looking closely at the cervix and vagina to see if there are any  abnormal or changed cells. It is done by a colposcopist, who is usually a gynaecologist, gynaecological oncologist or, in some clinics, a nurse practitioner.

A colposcopy takes only about 10–15 minutes. You will usually be advised not to have sex or put anything in your vagina (e.g. tampons) for 24 hours before the procedure.

A colposcopy is done with an instrument called a colposcope, which is a microscope with a light. The colposcope is placed near your genital area (vulva) but does not enter your body. You will lie on your back in an examination chair with your knees up and apart. The colposcopist will use a speculum to spread the walls of your vagina apart, and will usually apply a vinegar-like liquid and iodine to your cervix and vagina. This makes it easier to see any abnormal cells through the colposcope. You may feel a mild stinging or burning sensation, and you may have a brown discharge from the vagina after the procedure.

If the colposcopist sees any abnormal-looking areas during the colposcopy, they may take a tissue sample (biopsy) from the surface of the cervix. You may feel some pain for a short time while the tissue sample is taken.

You will be able to go home once the colposcopy and biopsy are done. The tissue sample is sent to a laboratory, and a pathologist will examine the cells under a microscope to see if they are abnormal (precancer or cancer). The results are usually available in about one week.

Side effects of a colposcopy with biopsy – After the procedure, it is common to have cramping that feels similar to pain you may have with your period (menstrual pain). This may last a short time and can be relieved with mild pain medicines such as paracetamol or non-steroidal anti-inflammatory drugs. You may also have some light bleeding or other vaginal discharge for up to a week.

To give the cervix time to heal and to reduce the risk of infection, your colposcopist may advise you not to have sexual intercourse or use tampons for a certain amount of time after the procedure.

"My doctor said that because I had regular cervical screening tests, the cancer was picked up while it was small.” KAREN

If any of the tests show precancerous cell changes, you may have one of the following procedures to remove the area of abnormal cells and prevent it developing into cervical cancer.

Large loop excision of the transformation zone

Large loop excision of the transformation zone (LLETZ) is the most common way to treat precancerous changes of the cervix. The abnormal tissue is removed using a thin wire loop that is heated electrically. The aim is to remove all the abnormal cells from the surface of the cervix. It may also be called loop electrosurgical excision procedure (LEEP).

The procedure is done under local anaesthetic in your doctor’s clinic or under local or general anaesthetic in hospital. A LLETZ takes about 5–10 minutes. The tissue sample is sent to a laboratory for examination under a microscope. Results are usually available in 1–2 weeks.

Side effects of a LLETZ – After the procedure, you may have some vaginal bleeding and cramping. These side effects will usually ease in a few days, but you may notice some spotting for several weeks.

See your doctor if the bleeding lasts longer than 3–4 weeks, becomes heavy or has an unpleasant smell, or you develop fever or intense pelvic pain. To give your cervix time to heal and to prevent infection, you should not have sexual intercourse or use tampons for 4–6 weeks after the procedure. Showers are fine, but avoid baths, spas and swimming pools for about 4 weeks as these can increase the risk of infection.

After a LLETZ you can still become pregnant, but you may have a slightly higher risk of having the baby prematurely. Talk to your doctor before the procedure if you are concerned.

This procedure is used when the abnormal cells are found in the cervical canal, if a larger area needs to be removed or when early-stage cancer is suspected. In some cases, a cone biopsy is also used to treat very early-stage cancers, particularly if you would like to have children in the future.

A cone biopsy is usually done as day surgery in hospital under general anaesthetic. A surgical knife (scalpel) is used to remove a cone-shaped piece of tissue from the cervix. A pathologist examines the tissue to make sure all the abnormal cells have been removed. Results are usually available in 1–2 weeks.

Side effects of a cone biopsy – After a cone biopsy, you may have some light bleeding or cramping for a few days. Avoid doing any heavy lifting for a few weeks, as the bleeding could become heavier or start again. If the bleeding lasts longer than 3–4 weeks, becomes heavy or has an unpleasant smell, or you develop fever or intense pelvic pain, see your doctor. You may notice a dark brown discharge for a few weeks, but this will pass. To give your cervix time to heal and to prevent infection, you should not have sexual intercourse or use tampons for 4–6 weeks.

A cone biopsy may weaken the cervix. You can still become pregnant after a cone biopsy, but you may be at a higher risk of having a miscarriage or having the baby prematurely. If you would like to become pregnant in the future, talk to your doctor before the procedure.

"I had period-like pain for a few days after the cone biopsy but a hot water bottle and mild pain medicines helped a lot.” JULIE

This procedure uses a laser beam instead of a knife to destroy or remove the abnormal cells.

A laser beam is a strong, hot beam of light. The laser beam is pointed at the cervix through the vagina. Laser surgery is done under either local or general anaesthetic. It takes about 5–10 minutes, and you can go home after the treatment when you have recovered from the anaesthetic.

Laser surgery works just as well as a LLETZ to remove precancerous cells and can be a better option if the precancerous cells extend from the cervix into the vagina or if the lesion on the cervix is very large.

Side effects of laser surgery – These are similar to those of LLETZ. You are usually able to return to your usual activities 2–3 days after having laser surgery, but you should not have sexual intercourse or use tampons for 4–6 weeks. You will also need to avoid baths, swimming pools and spas.

If any of the tests or procedures show that you have cervical cancer, you may need further tests to find out whether the cancer has spread to other parts of your body. This is called staging.  You may have one or more of the tests described below.

Blood test

You may have a blood test to check your general health, and how well your kidneys and liver are working.

Imaging scans

Various imaging scans can create pictures of the inside of your body and provide different types of information. You may have one or more of the following imaging scans to find out if the cancer has spread to lymph nodes in the pelvis or abdomen, or to other organs in the body.

CT scan – A CT (computerised tomography) scan uses x-rays to take pictures of the inside of your body and then compiles them into a detailed, 3-dimensional picture.

When you make the appointment for the scan, you will be told if there are any special instructions to follow. Before the scan, you may be given a drink, or have an injection of a dye (called contrast) into one of your veins. The contrast may make you feel hot all over for a few
minutes. You may also be asked to insert a tampon into your vagina. The dye and the tampon make the pictures clearer and easier to read.

During the scan, you will need to lie still on a treatment table that moves in and out of the CT scanner, which is large and round like a doughnut. The scan is painless and takes 5–10 minutes.

MRI scan – An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to create detailed cross-sectional pictures of the inside of your body. Let your medical team know if you have a pacemaker or any other metal implant, as some may affect how an MRI works.

Sometimes gel is placed in the vagina before the MRI scan to better show the cervix or vagina. During the scan, you will lie on a treatment table that slides into a large metal cylinder that is open at both ends.

The test is painless but the noisy, narrow machine can make some people feel anxious or claustrophobic. If you are concerned, talk to your medical team before the scan. You may be given medicine to help you relax, and you will usually be offered headphones or earplugs. Most MRI scans take between 30 and 90 minutes.

PET–CT scan – A PET (positron emission tomography) scan combined with a CT scan is a specialised imaging test. It provides more detailed information about the cancer than a CT scan on its own. Not all people need to have a PET–CT scan.

Before having the scan, you will be injected with a glucose (sugar) solution containing a small amount of radioactive material. Cancer cells show up brighter on the scan because they take up more glucose than normal cells do. The radioactive material will leave your body within a few hours.

You will be asked to lie still for 30–60 minutes while the solution spreads through your body, then you will have the scan. Let your doctor know if you are claustrophobic, as you need to be in a confined space for the scan. It may take a few hours to prepare for a PET–CT scan, but the scan itself usually takes about 30 minutes.

Before having scans, tell the doctor if you have any allergies or have had a reaction to contrast during previous scans. You should also let them know if you have diabetes or kidney disease, or are pregnant or breastfeeding.

Examination under anaesthetic

Another way to check whether the cancer has spread is for the doctor to examine your cervix, vagina, uterus, bladder and rectum. This is done in hospital under general anaesthetic.

If the doctor sees any abnormal areas of tissue during the procedure, they will usually take a biopsy. The area examined will depend on where the cancer may have spread to and may include:

Pelvic examination – The doctor will put a speculum into your vagina and spread the walls of the vagina apart so the doctor can check the cervix and vagina for cancer.

Uterus – The cervix will be dilated (gently opened) and some of the cells in the lining of the uterus (endometrium) will be removed and sent to a laboratory for examination. This is called a dilation and curettage (D&C).

Bladder – To examine the bladder, the doctor will insert a thin viewing instrument with a camera and light on the end (a cystoscope) into your urethra. The urethra is the tube that drains urine (wee) from the bladder.

Rectum – The doctor will wear gloves and use a finger to feel for any abnormal growths inside your rectum. To examine your rectum more closely, the doctor may insert an instrument called a sigmoidoscope, which is a tube with an attached camera.

For people who will be having radiation therapy, the doctor may implant small markers into the cervix or vagina to show the size and position of the cancer. The markers (called fiducials) are made of gold and are about the size of a grain of rice. They can be seen on x-ray and CT scans and are used to guide radiation therapy treatment.

You can usually go home from hospital on the same day after an examination under anaesthetic. You may have some light bleeding and cramping for a few days afterwards. Your doctor will talk to you about any other side effects you may have.

For some people, surgery may be the only treatment needed. Surgery is usually recommended when the tumour is in the cervix only. The type of surgery you have will depend on how far within the cervix the cancer has spread. Your gynaecological oncologist may also remove some lymph nodes during surgery.

If becoming a parent is important to you, talk to your doctor before starting treatment and ask for a referral to a fertility specialist.

Types of surgery

Depending on how far the cancer has spread and your age, you may have one or more of the procedures listed below.

Cone biopsy – Removes a cone-shaped piece of tissue around the cancer, including a margin of healthy tissue. A cone biopsy is used to treat very early cervical cancers. You may have this if
you would like to have children.

Trachelectomy – Removes part or all of the cervix, along with the upper part of the vagina. The uterus, fallopian tubes and ovaries are left in place. This is not a common procedure, but it may be used if you have early-stage cancer and would like to have children.

Total hysterectomy – Removes the uterus and cervix. This surgery can be used for early cervical
cancers. The fallopian tubes are also commonly removed. You may be able to keep your ovaries if you are premenopausal.

Radical hysterectomy – Removes the uterus, cervix, and soft tissue around the cervix and top of the vagina. This is the standard operation for most cervical cancers treated with surgery. The fallopian tubes are also commonly removed. You may be able to keep your ovaries if you are premenopausal.

Bilateral salpingectomy – Removes both fallopian tubes. A bilateral salpingectomy may be
recommended if you are having a total or radical hysterectomy.

Bilateral salpingo-oophorectomy – Removes both fallopian tubes and ovaries. This may be considered for those who are having a hysterectomy when there is a risk that the cancer may have spread to the ovaries, which may happen with adenocarcinoma. This procedure may be
recommended before or after menopause.

How the surgery is done

Depending on how far the cancer has spread and your age, you may have one or more of the procedures listed above. The surgery will be performed under a general anaesthetic. Research has shown that outcomes for larger cervical cancers are better with open surgery (laparotomy). This means that the surgery is performed through a cut in the abdomen. The cut is usually made from the pubic area to the bellybutton. Sometimes the cut is made across the pubic hair line instead. The uterus and other organs are then removed through the cut. Keyhole surgery (laparoscopy or robotic surgery) is usually only used for very early cervical cancer. Your surgeon will talk to you about the most suitable surgery for you, as well as any risks.

Surgery to remove lymph nodes

You may have one of the following procedures to check if the cancer has spread from the cervix to lymph nodes in the pelvis. If cancer is found in the lymph nodes, your doctors may recommend additional treatment.

Lymphadenectomy (lymph node dissection) – The surgeon will remove a number of lymph nodes from the pelvic and/or abdominal areas to see if the cancer has spread beyond the cervix.

Sentinel lymph node biopsy – This procedure may be used for early cervical cancer but is only performed in some treatment centres. It helps to find the lymph node that the cancer is most likely to spread to first (the sentinel lymph node). While you are under anaesthetic, your surgeon will inject a dye into the cervix. The dye will flow to the sentinel lymph node and the surgeon will remove it for testing. If it contains cancer cells, the surgeon may remove the remaining nodes in the area (lymphadenectomy). Alternatively, your doctors may decide you need other treatments such as chemoradiation. A sentinel lymph node biopsy can help avoid the removal of more lymph nodes than necessary and minimise side effects such as lymphoedema.

What to expect after surgery

When you wake up from surgery, you will be in a recovery room near the operating theatre.  Once you are fully conscious, you will be taken to your bed on the hospital ward.

Tubes and drips – You may have an intravenous (IV) drip to give you fluid and medicine (such as pain medicine or antibiotics to prevent infection), a tube in your abdomen to drain fluid from the operation site, and a small plastic tube (catheter) in your bladder to drain urine (wee). These tubes will be removed before you go home.

After the catheter is removed from your bladder, the nurses will check that your bladder is emptying properly. This is called a bladder scan. It is a quick, painless scan that is done on the hospital ward.

Pain and discomfort – After a major operation, it is common to feel some pain. You will be given pain medicine as a tablet (orally), through a drip (intravenously) or through a catheter inserted in the spaces in the spine (epidural). If you still have pain, let your doctor or nurse know so they can change your medicine to one that provides more relief.

Blood clot prevention – You will usually have injections of a blood-thinning drug to reduce the risk of blood clots. While you are in bed, you may have to wear compression stockings on your lower legs. These stockings help the blood in your legs circulate and prevent blood clots forming in the deep veins of the legs or pelvis (deep vein thrombosis). You will be encouraged to walk around as soon as you can and you may be asked to continue injecting blood-thinning drugs for several weeks after returning home.

Recovery – You will usually spend up to 5 days in hospital after surgery. The recovery time depends on the type of surgery, your fitness and whether you have any complications. You will be able to go home when the treatment team is satisfied with your recovery and the results of your bladder scans.

Side effects after surgery

After surgery for cervical cancer, you may have some side effects.

Problems with how the bladder works – Some of the nerves to the bladder may be affected by a hysterectomy. You may feel that you’re not able to empty your bladder completely or that you’re emptying your bladder very slowly. These problems usually improve with time. You may also find that you leak some urine after surgery. This is called urinary incontinence.

Constipation – The pain medicines used during and after surgery can cause constipation (difficulty having bowel movements). Your treatment team may suggest medicines to help prevent or relieve constipation. Once your surgeon says you can get out of bed, walking around can also help.

Impact on sexuality – The physical and emotional changes you have after surgery may affect how you feel about sex, but surgery doesn’t change the ability to feel pleasure.

Lymphoedema – Sometimes removing lymph nodes in the pelvic area can stop or slow the natural flow of lymphatic fluid from the legs. This may cause lymphoedema – a build-up of fluid in the soft tissues under the skin – in the legs or genital area.

Menopause – If your ovaries are removed and you have not been through menopause, removal will cause sudden menopause. After menopause, you will stop having periods and you will not be able to become pregnant. If you are finding it hard to manage the symptoms of menopause, you may be able to take menopausal hormone therapy (MHT).

Internal scar tissue (adhesions) – Scar tissue in the pelvis may stick together. Sometimes these adhesions, particularly to the bowel or bladder, may cause abdominal pain or discomfort.  Rarely, adhesions may need to be treated with surgery.

Taking care of yourself at home after surgery

Your recovery time after surgery will depend on the type of operation you had, your age and general health. In most cases, you will feel better within 6 weeks.

Rest up – Take things easy for the first few weeks after the surgery. Ask family or friends to help you with household chores so you can rest as much as you need to.

Activity and exercise – Walk regularly if your doctors say it is okay to do so. Gentle exercise can help speed up recovery. Speak to your doctor about when you can start more vigorous exercise or go swimming.

Work – Depending on the type of work you do, you will probably need up to 4–6 weeks leave from your job.

Lifting – Avoid heavy lifting for 6 weeks, maybe more depending on the type of surgery you’ve had.

Sex – You’ll need to avoid sexual intercourse for at least 6 weeks after surgery to give the vaginal wound time to heal properly.

Download our booklet ‘Understanding Surgery’

Also known as radiotherapy, radiation therapy uses a controlled dose of radiation to kill or damage cancer cells. The radiation is usually in the form of x-ray beams. It is targeted at the parts of the body with cancer or at areas the cancer cells might have spread to. Treatment is
carefully planned to do as little harm as possible to healthy tissues.

Radiation therapy may be given in combination with chemotherapy as the main treatment for cervical cancer (chemoradiation) or after surgery to help destroy any remaining cancer cells and reduce the chance of the cancer coming back (adjuvant therapy).

There are 2 main ways of delivering radiation therapy: externally or internally. It is common to have both types to treat cervical cancer.

External beam radiation therapy

In external beam radiation therapy (EBRT), a machine precisely directs radiation beams from outside the body to the cervix, lymph nodes and other organs that need treatment. You will have a planning session, including a CT scan, to work out where to direct the radiation. To help direct the treatment, up to 4 small tattoos the size of a freckle may be applied to the skin on your pelvis. These marks are usually permanent.

You may be asked to empty your bowels and/or drink some water so that your bladder is comfortably full before the CT scan and treatments. This helps to ensure that organs in the pelvic area – including the cervix and uterus – are in the same position for each treatment and the radiation beams are delivered to the targeted area.

You will probably have EBRT as daily treatments, Monday to Friday, over 4–6 weeks as an outpatient. You will lie on a table and the radiation therapy machine will move around you. It is important that you lie still and breathe normally. The radiation therapist will leave the room
during treatment, but will be able to talk to you through an intercom and watch you on a screen. The EBRT session may take up to 45 minutes, but the actual treatment takes about 15 minutes and is painless.

Internal radiation therapy

Also known as brachytherapy, internal radiation therapy delivers radiation directly to the tumour from inside your body (usually through the vagina). It allows a higher radiation dose to be delivered to the tumour, while reducing the amount of radiation delivered to nearby organs such as the bowel and bladder. Brachytherapy is usually given after the course of EBRT is  finished. The main type of internal radiation therapy used for cervical cancer is high-dose-rate (HDR) brachytherapy.

With HDR brachytherapy, only a few treatments are needed to receive the required radiation dose. Your treatment team will develop a personalised treatment plan to suit your body and target the cancer while limiting the radiation dose to other organs.

You will have treatment as a day patient or may stay in hospital overnight. You will probably have 3–4 sessions over 2–3 weeks, and will be given a general or spinal anaesthetic at each session.

During treatment – Devices called applicators are used to deliver the radiation source to the cancer. They are available in different sizes. Your radiation oncologist will examine you to choose suitable applicators for your situation. Applicators are placed into the cervix under ultrasound guidance to make sure they are in the right place. To hold the applicators in place, you will have gauze padding put into your vagina, and may have a stitch placed in the vulva.

You will also have a small tube (catheter) inserted to empty your bladder of urine during treatment. You will have a CT or MRI scan to check the position of the applicator. If you have a general anaesthetic, you may be woken after the applicator is put in place and given patient-controlled pain medicine for the rest of the procedure.

The radiation dose is delivered from a shielded container through cables to the applicator. The radiation stays in the applicator for about 10–20 minutes and is then taken out.

External beam radiation therapy and HDR brachytherapy will not make you radioactive. It is safe for you to be with both adults and children after your treatment sessions.

After treatment – As several sessions are needed, you may stay in hospital with the applicator in place (and no radiation inside) so that a second treatment can be given. Otherwise, the applicator may be taken out after the radiation dose is delivered and then reinserted before each session.

After brachytherapy, you may feel uncomfortable in the vaginal region or have a small amount of bleeding. Pain medicines can help.

Radiation therapy after surgery (adjuvant therapy)

If you’ve had surgery, your doctor may recommend that you also have additional radiation therapy. Usually, about 4–6 weeks after surgery, you will have EBRT in combination with chemotherapy. Occasionally, some women will have brachytherapy to deliver radiation to the top of the vagina.

This brachytherapy is done as an outpatient procedure and does not require anaesthetic. A cylinder-shaped applicator is inserted into the vagina, then removed after each session. You may need to have 2–4 sessions to deliver the right amount of radiation to treat the cancer. Each treatment session takes about 30 minutes.

Short-term side effects of radiation therapy

The side effects you have will vary depending on the dose of radiation and the length of the treatment. Many will be short-term side effects that occur during treatment or within a few weeks of finishing. Side effects can take several weeks to get better.

Fatigue – Your body uses a lot of energy dealing with the effects of radiation on healthy cells. Tiredness usually builds up slowly during the course of the treatment, particularly near the end. It may last for some time after treatment ends.

Bladder and bowel changes – You may pass urine more often or with more urgency, or feel a burning sensation. Try to drink plenty of water to dilute your urine. Bowel movements may be more frequent, urgent or loose (diarrhoea), or you may pass more wind than normal. Less commonly, there may be some blood in the faeces (poo or stools). Your treatment team will prescribe medicines to reduce these side effects.

Hair loss – When radiation therapy is aimed at your pelvic area, you may lose your pubic hair. This hair may grow back after the treatment ends, but it will usually be thinner. The radiation
therapy will not cause you to lose hair from your head or other parts of your body

Vaginal discharge – Radiation therapy may cause or increase vaginal discharge. Let your treatment team know if it smells different or has blood in it. Do not wash inside the vagina with water or other fluids as this may cause infection.

Long-term or late effects of radiation therapy

Some side effects may continue for longer. Other side effects from radiation therapy may not show up until many months or years after treatment. These are called late effects.

Lymphoedema – Radiation can scar the lymph nodes and vessels and stop them draining lymph fluid properly. This may lead to swelling of the legs or genital area. This can occur months or years after radiation therapy.

Bladder and bowel changes – Bladder and bowel changes can also be late effects, appearing months or years after radiation therapy finishes. You may pass urine or stools (poo) more often or need to go in a hurry. Sometimes, changing your diet and avoiding spicy and fatty foods can help. Let your doctor know if you have any bleeding or have pain in the abdomen and cannot
open your bowels.

Narrowing of the vagina – The vagina may become drier, shorter and narrower (vaginal stenosis), which may make sex and follow-up pelvic examinations uncomfortable or difficult. Your treatment team will suggest strategies to prevent this, such as using vaginal dilators.

Menopause – If your ovaries have not been removed, radiation therapy will stop the ovaries producing hormones, which leads to early menopause. Your periods will stop, you will no longer be able to become pregnant and you may have menopause symptoms.

Pelvic fracture – Rarely, radiation therapy to the pelvic area can weaken bones and cause a fracture. Pelvic fractures are the most common. This may not happen until 2–4 years after treatment. The risk is higher after menopause and if you have low bone density (osteoporosis).

Download our booklet ‘Understanding Radiation Therapy’

Chemotherapy uses drugs to kill cancer cells or slow their growth while causing the least possible damage to healthy cells. It may be given:

• in combination with radiation therapy as the main treatment for cervical cancer (chemoradiation)
• on its own or combined with targeted therapy.

The drugs are usually given through a vein (intravenously) during day visits to a hospital or clinic. Chemotherapy is usually given as a period of treatment followed by a break. This is called a cycle. The number of cycles you have depends on the type of cervical cancer and any other treatments you may be having. If you have chemotherapy without radiation therapy, you are likely to have up to 6 cycles (with a cycle every 3–4 weeks), though it may continue for longer.

Side effects of chemotherapy – The possible side effects vary according to the drugs given, how often you have treatment, your general health, and whether you have chemotherapy alone or chemoradiation. You may have nausea or vomiting; feel tired; or lose some hair from your body or head. Temporary or permanent menopause may also occur.

Chemotherapy may reduce the number of blood cells in your body, so you will have regular blood tests during treatment to monitor this. Depending on the type of blood cells affected, you may feel very tired and be more likely to get infections. If your temperature rises to 38°C or above, go to the nearest hospital emergency department immediately.

Most side effects of chemotherapy are temporary, and your treatment team can help you to prevent or reduce them. 

Download our booklet ‘Understanding Chemotherapy’

When radiation therapy is given at the same time as chemotherapy, it is known as chemoradiation. The chemotherapy drugs make the cancer cells more sensitive to radiation therapy.

If you have chemoradiation, you will usually receive chemotherapy once a week a few hours before the radiation therapy appointment.

Side effects of chemoradiation include fatigue; diarrhoea; needing to pass urine more often or in a hurry; cystitis (irritation of the bladder); dry and itchy skin in the treatment area; and nausea.

Chemoradiation can also affect blood cells, and weekly blood tests may be needed during treatment to monitor your blood cell levels.

Talk to your treatment team about ways to manage the side effects of chemoradiation.

Targeted therapy is a drug treatment that attacks specific features of cancer cells to stop the cancer growing and spreading. It is used to treat cervical cancer that has spread to other parts of the body or has come back and cannot be treated by surgery or radiation therapy.

Bevacizumab is a type of targeted therapy that can be used to treat advanced cervical cancer. It is given with chemotherapy every 3 weeks through a drip into a vein (infusion). The total number of infusions you receive will depend on how you respond to the drug.

Side effects of targeted therapy – The most common side effects of taking bevacizumab include high blood pressure, feeling tired and loss of appetite. Less common side effects include bleeding, blood clots and problems with wound healing. Rarely, bevacizumab has the potential to cause other more serious side effects, such as damage to the bowel (perforation) or the development of an abnormal opening between the vagina and another part of the body (fistula). Your doctor will discuss these possible side effects with you.

Download our fact sheet ‘Understanding Targeted Therapy’

Immunotherapy is a type of drug treatment that helps the body’s own immune system to fight cancer.

Pembrolizumab is an immunotherapy drug that may be offered to certain people with cervical cancer that has not responded to treatment, has spread or has come back. Pembrolizumab is given with chemotherapy drugs and sometimes with bevacizumab.

Side effects of immunotherapy – Immunotherapy can have a range of side effects. Because this therapy is given with chemotherapy there may also be side effects related to the chemotherapy. Common side effects of pembrolizumab include fatigue, diarrhoea, itching and joint pain.

Rarely, pembrolizumab can affect other organs including the heart, lungs, bowel or thyroid gland and these side effects can sometimes be life-threatening. It’s important to let your treatment team know about any new or worsening side affects during or after treatment. Don’t try to treat side effects yourself.

Download our fact sheet ‘Understanding Immunotherapy’

Palliative treatment helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. It is best thought of as supportive care.

Many people think that palliative treatment is only for people at the end of their life, but it may help at any stage of advanced cervical cancer. It is about living for as long as possible in the most satisfying way you can.

As well as slowing the spread of cancer, palliative treatment can relieve any pain and help manage other symptoms. Treatment may include radiation therapy, chemotherapy, targeted therapy or other medicines such as hormone therapy.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, practical, cultural, social and spiritual needs. The team also provides support to families and carers.

Download our booklet ‘Understanding Palliative Care’

Download our booklet ‘Living with Advanced Cancer’

Bladder control may change after surgery or radiation therapy. You may find that you need to pass urine (wee) more often or in a hurry. Or you may leak a few drops of urine when you cough, sneeze, laugh, strain or lift. This is called urinary incontinence and there are ways to manage it, including strengthening your pelvic floor muscles. You can find a guide to exercising the pelvic floor muscles in our ‘Exercise for People Living with Cancer’ booklet.

Using continence pads and special underwear can help you manage leakage. You may be eligible for help with the cost of these products. Visit Services Australia for more information. You might also find it helpful to see a continence nurse or physiotherapist for a bladder training program – ask your doctor for a referral or visit the National Continence Helpline or call them on 1800 33 00 66.

The blood vessels in the bladder can break more easily after radiation therapy. This can cause blood to appear in urine or faeces (poo), even months or years after treatment. Let your doctor know if this occurs so the problem can be treated.

After surgery or radiation therapy, you may notice changes in your bowel habits. You may have constipation or diarrhoea, or feel pain in your abdomen from trapped wind.

Radiation proctitis – Radiation therapy can damage the lining of the rectum, causing inflammation and swelling known as radiation proctitis. The risk of developing radiation proctitis is low and your treatment team will try to reduce this risk. Radiation proctitis is usually a short-term side effect but may be ongoing in a small number of people. It can cause a range of symptoms including: blood in bowel movements; diarrhoea; the need to empty the bowels urgently; and loss of control over the bowels (faecal incontinence).

You may develop some of these symptoms for other reasons. Let your treatment team know if you develop any of these symptoms. If you have ongoing bowel problems, you may be referred to a gastroenterologist.

Tips for managing bowel changes

• Drink peppermint or chamomile tea to reduce abdominal or wind pain.
• Drink plenty of water to replace fluids lost through diarrhoea or to help soften stools if you’re constipated.
• Avoid alcohol and cut down on coffee, cola and other drinks that contain caffeine.
• Avoid spicy and fatty foods.
• See a women’s health physiotherapist for information about exercises to strengthen your pelvic floor and anal muscles. Also see our information for ‘Exercise for People Living with Cancer’.
• Talk to your doctor or a dietitian about what to eat, or ask about suitable medicines.

Having cervical cancer can affect your sexuality in physical and emotional ways. The impact of these changes depends on many things, such as the treatments you have and any side effects, whether you have a partner, and your overall self-confidence.

Low libido – A lack of interest in sex or loss of desire is common during and after treatment. This may be because of the worry of having cancer and the side effects of treatment. If you do not feel like having sex, or if you find it uncomfortable, let your partner know.

Vaginal changes – The main side effect of treatment for cervical cancer will be to the vagina. If the ovaries have been affected by surgery or radiation therapy, they will no longer produce oestrogen. This will cause your vagina to become very dry and it may not expand easily during sexual intercourse. Radiation therapy to the pelvic area can also cause vaginal tissue to lose its elasticity and shrink, narrowing the vagina. This is called vaginal stenosis. If vaginal changes make sexual penetration difficult or painful, you may have to explore different ways to enjoy sex. Even if you don’t plan to have sex, your doctor will need to do regular pelvic examinations after treatment, so it’s important to prevent vaginal stenosis.

"Using vaginal dilators helped. The plastic vaginal dilators the hospital gave me were sturdy, white and horrible…so I bought my own. Buying pretty, silicone dilators gave me a sense of control, and
they were a lot more comfortable to use.” JANE

Managing changes in your sex life

Sexual changes

• Give yourself time to get used to any physical changes.
• Talk to your doctor about ways to manage side effects that change your sex life. They may suggest using hormone creams and vaginal moisturisers to help with vaginal discomfort and dryness. You can get a prescription for hormone creams from your doctor or buy vaginal moisturisers over the counter from pharmacies.
• Discuss changes to your libido with your partner so they understand how you’re feeling.
• Consider touching, hugging and kissing. This is a chance to feel close to your partner without expectations of sexual penetration.
• Explore other ways to experience sexual pleasure, such as caressing the breasts, thighs, feet or buttocks.
• Use water- or silicone-based vaginal lubricants (without perfumes, oils or glycerines) to make penetration comfortable.
• If you need more support, ask your doctor for a referral to a sex therapist or psychologist.

Changes to the vagina

• Keeping the vagina open and supple will make sexual intercourse more comfortable. Even if you don’t plan to be sexually active, it also makes it easier for your doctor to do regular vaginal examinations to check whether the cancer has come back.
• Your doctor or nurse may suggest you use a vaginal dilator to help keep the walls of the vagina open and supple.
• Dilators are tube-shaped devices made from plastic or silicone. They are designed to gently stretch the vagina. They come in different sizes – it is important to seek advice from a health professional about the correct size.
• Wait until any soreness has settled before you start using a dilator. This is usually 2–6 weeks after your last session of radiation therapy.
• Used with lubricant, the dilator is inserted into the vagina for short periods of time.
• Using a dilator can be challenging. Your doctor, nurse or a physiotherapist can provide practical advice on how to use them.

Download our booklet ‘Sexuality, Intimacy and Cancer’

It is common to feel tired and lack energy during and after treatment, particularly if you’ve had both radiation therapy and chemotherapy. The tiredness may continue for several months, or even a year or two, after treatment has finished.

Feeling tired is not only a side effect of the treatment itself. Travelling to hospitals and clinics for treatment can be exhausting. If you work during your treatment or if you have a family to care for, this can make you feel especially tired.

It may be frustrating if other people don’t understand how you’re feeling.

Tips for managing fatigue

• Gentle exercise during and after treatment has been shown to boost energy levels and reduce fatigue. Ask your doctor about the amount and type of exercise that is right for you.
• Plan your day. Do things at the time of day when you have more energy.
• Rest regularly. Keep a journal to track your “good times” and pace your activities so you manage your energy over the day.
• Talk with your family and friends about how you’re feeling and discuss things they can help you with (e.g. housework and shopping).
• Limit daytime naps to 30 minutes so you don’t have trouble sleeping at night.
• Don’t expect to be able to instantly do everything you used to do. Your body is still recovering and it will take some time for your energy levels to return.

Download our fact sheet ‘Fatigue and Cancer’

If your uterus is removed or you have radiation therapy to the uterus and cervix, you will not be able to conceive children or carry a pregnancy. Before treatment starts, ask your doctor or a fertility specialist about what options are available to you.

Being told that your reproductive organs will be removed or will no longer work can be devastating. Even if your family is complete or you did not want children, you may still feel a sense of loss and grief. These reactions are common. Speaking to a counsellor or gynaecological oncology nurse about your feelings can be helpful.

Ways to preserve fertility

• Ovarian transposition (oophoropexy) is a type of surgery that moves one or both ovaries to limit the amount of radiation the ovaries receive. This can help to keep the ovaries working after treatment.
• If you have not already been through menopause, ask about ways to preserve your fertility. One option may be to store eggs or embryos for use in the future. These can be implanted in your body, if you still have a healthy uterus, or into a surrogate.
• Having a trachelectomy, where only the cervix is removed, may be an option. It will still be possible to become pregnant after this procedure, but you will be at higher risk of miscarriage and having the baby prematurely. Your doctor can discuss these risks with you.

"The first time I met my surgeon she said, ‘You should go and see a fertility specialist’. The only way to describe the process is that it was overwhelming. However, it’s better not to delay it.” MACKENZIE

Download our booklet ‘Fertility and Cancer’

Surgery or radiation therapy to the pelvic area can stop lymph fluid from draining normally, causing swelling in the legs or genital area. This is known as lymphoedema. Lymphoedema may appear during treatment or months or years later.

It is important to look after your skin, avoid injury or infection to the lower limbs, and manage lymphoedema symptoms as soon as possible. Mild lymphoedema is usually managed with exercise, skin care and a compression stocking or sleeve. A physiotherapist trained in lymphoedema management can give you further advice.

To find a practitioner who specialises in the management of lymphoedema, visit the Australasian Lymphology Association.

Download our fact sheet ‘Understanding Lymphoedema’

If your ovaries have been damaged by radiation therapy or chemotherapy, or they’ve been surgically removed, your body will no longer produce the hormones oestrogen and progesterone. When this happens, periods stop. This is called menopause. Menopause is a natural and gradual process that usually starts between the ages of 45 and 55.

The symptoms of menopause caused by cancer treatment are usually more severe than during a natural menopause because the body hasn’t had time to adjust to a gradual decrease in the hormone levels. Symptoms can include hot flushes, mood swings, trouble sleeping (insomnia), tiredness and vaginal dryness.

Menopause may cause other changes in the body over time, such as:

• low libido – you may be less interested in sex
• osteoporosis – this is when your bones become weak and brittle and may break more easily
• high cholesterol – cholesterol is a fatty substance found in the blood; having high levels can increase your risk of heart disease and stroke.

Menopausal hormone therapy (MHT), previously known as hormone replacement therapy (HRT), is medicine that replaces the hormones usually produced by the ovaries. It has been shown to treat menopause symptoms and help prevent osteoporosis. There are also non-hormonal drugs that can help. Talk to your doctor about the risks and benefits of MHT, and other ways to deal with the symptoms of menopause.

How to manage menopause symptoms

• Talk to your doctor about having a bone density test or taking medicines to prevent osteoporosis. Regular exercise can help keep your bones strong. Visit Healthy Bones Australia or call them on 1800 242 141.
• Ask your doctor to check your cholesterol levels. If levels are high, regular exercise and a balanced diet may help reduce them. If levels don’t improve, talk to your doctor about
  cholesterol-lowering drugs.
• Your doctor can suggest dietary changes and suitable exercises.
• If you smoke, talk to your doctor about quitting or call the Quitline on 13 7848.
• Try meditation and relaxation techniques to help reduce stress and lessen symptoms. Listen to our ‘Finding Calm During Cancer’ podcast series.
• If you have ongoing symptoms, ask your doctor for a referral to a specialist menopause clinic.

After treatment ends, you will have regular appointments with your specialists to monitor your health, manage any long-term side effects and check that the cancer hasn’t come back (recurred) or spread.

During check-ups, you will usually have a pelvic examination, and you may have a follow-up HPV and liquid-based cytology (LBC) tests, blood tests, and imaging scans. Your doctor will discuss your follow-up schedule with you. For the first few years, you will probably have a check-up every 3–6 months. Check-ups will become less frequent (once a year) if you have no further problems.

When a follow-up appointment is approaching, many people feel anxious. Talk to your treatment team or call Cancer Council 13 11 20 if you are finding it hard to manage this anxiety.

While the risk of most cervical cancers coming back is very low, it does return for some people (called a recurrence). This is why it is important to have regular check-ups and to report any symptoms immediately, rather than waiting for your next follow-up appointment.

If the cancer does recur, you will usually be offered further treatment to remove the cancer or help control its growth. If you had radiation therapy the first time you had treatment, you may not be able to have further radiation therapy.

New drug treatments to treat the recurrence may be available through clinical trials. Ask your doctor about recent developments and whether a clinical trial may be an option for you.

If you have continued feelings of sadness, have trouble getting up in the morning or have lost motivation to do things that previously gave you pleasure, you may be experiencing depression. This is quite common among people who have had cancer.

Talk to your GP, because counselling or medication – even for a short time – may help. Some people can get a Medicare rebate for sessions with a psychologist. Cancer Council SA also offers a free counselling service.

For information about coping with depression and anxiety, visit Beyond Blue or call them on 1300 22 4636. For 24-hour crisis support, visit Lifeline or call them on 13 11 14.