Cervical cancer and fertility

January is cervical cancer awareness month and according to WHO we can end it if we get informed, screened, and vaccinated. Also according to the organization, cervical cancer is the 6th most common cancer in women in the Eastern Mediterranean Region. In 2020, an estimated 89,800 women were diagnosed with cervical cancer in the Region and more than 47,500 women died from the disease. So, let’s get a little more well-informed on what cervical cancer is, which are the causes and symptoms, how it can be treated and how it affects fertility. 

Contents:

• What is cervical cancer?
• Causes
• Symptoms
• Diagnosis
• Treatment
• Cancer and fertility

What is cervical cancer?

Cervical cancer is the growth of abnormal cells in the lining of the cervix, the lower, narrow end of the uterus that forms a canal between the uterus and vagina. The most common cervical cancer is squamous cell carcinoma, accounting for 70% of cases. Adenocarcinoma is less common (about 25% of cases) and more difficult to diagnose because it starts higher in the cervix. 

Squamous cell carcinoma (SCC): One of the three main types of cells in the top layer of the skin (the epidermis), squamous cells are flat cells located near the surface of the skin that shed continuously as new ones form. SCC occurs when DNA damage from exposure to ultraviolet radiation or other damaging agents trigger abnormal changes in the squamous cells. SCCs can also occur in other areas of the body, including the genitals.

The incidence of cervical cancer has significantly decreased since the National Cervical Screening Program began in 1991 and because of the national Human Papilloma Virus (HPV) vaccine program that was introduced in 2007. The chance of surviving cervical cancer for at least five years is 74%.

HPV vaccination: 

For children: Ages 11–12 years should get two doses of HPV vaccine, given 6 to 12 months apart. HPV vaccines can be given starting at age 9 years. Children who start the HPV vaccine series on or after their 15th birthday need three doses, given over 6 months.

For adults: Everyone through the age of 26 years old should get HPV vaccine if they were not fully vaccinated already.

HPV vaccination is not recommended for everyone older than age 26 years.

• Some adults between 27 and 45 years old who were not already vaccinated might choose to get HPV vaccine after speaking with their doctor about their risk for new HPV infections and the possible benefits of vaccination for them.
• HPV vaccination of adults provides less benefit because more people in this age range are exposed to HPV already.

In general the chance of surviving cervical cancer for at least five years is 74%.

Causes of cervical cancer:

Almost all cases of cervical cancer are caused by persistent infection with some high-risk types of the human papillomavirus (HPV). HPV is the name of a very common group of viruses, which usually do not cause any problems in most people, but some types can cause genital warts or cancer. 

Another risk factor for this type of cancer is smoking. We have again pointed out how important it is for you to lead a healthy lifestyle away from all kinds of abuse, such as smoking and drinking. Both of the above are hurting your fertility levels too. 

There is some evidence that women who have taken the contraceptive pill for five years or more are at increased risk of developing cervical cancer. The risk is small and taking the pill has also been shown to reduce the risk of other cancers such as ovarian and uterine, so the results are not definite.

Around 8 out of 10 women will become infected with genital HPV at some time in their lives, but most of them who have the HPV infection never get cervical cancer as only a few types of the HPV result in cervical cancer.

Symptoms of cervical cancer:

The only way to know if there are abnormal cells that may develop into cancer is to have a cervical screening test. If early cell changes develop into cervical cancer, the most common signs will include:

• vaginal bleeding between periods
• menstrual bleeding that is longer or heavier than usual
• pain during intercourse
• bleeding after intercourse
• pelvic pain
• a change in your vaginal discharge such as more discharge or it may have a strong or unusual color or smell
• vaginal bleeding after menopause

Diagnosis of cervical cancer:

The usual tests that identify cervical cancer are:

• Colposcopy with biopsy: A colposcopy identifies where abnormal cells are located in the cervix, and what they look like. A speculum is inserted into the vagina so that the doctor can view the cervix and vagina via a colposcope, an instrument that magnifies the area, like binoculars. The procedure is done by a colposcopist – usually a gynecologist or, in some clinics, a nurse practitioner.
• Large loop excision of the transformation zone (LLETZ) or cone biopsy: If any of the tests show precancerous cell changes you may have a large loop excision procedure or a cone biopsy. LLETZ is the most common method to remove cervical tissue for examination and treating precancerous changes of the cervix. It is usually done under a local anesthetic. A cone biopsy is used where there are abnormal glandular cells in the cervix or if early-stage cancer is suspected.

Treatment of cervical cancer:

Depending on the severity of cancer, it is staged from stage 1, where abnormal cells are found only in the tissue of the cervix to stage 4, when cancer has spread beyond the pelvis to the lung, liver, or bones. This helps your doctor to plan the best treatment for you.

For early and non-bulky disease (less than 4 cm), treatment is surgery, sometimes with chemoradiation therapy afterwards.

If the tumor is small, a cone biopsy may suffice; in some cases, a hysterectomy (surgical removal of the uterus) is required.

For locally advanced diseases, a combination of radiation therapy (radiotherapy) and chemotherapy (cisplatin) is used.

For metastatic disease, the treatment is chemotherapy or palliative care alone.

Cervical cancer and fertility.

So what do all the above mean regarding your ability to conceive?

In most cases, unfortunately conceiving will be difficult to impossible. This is because you may have to:

• surgically remove the womb (with a radical hysterectomy)
• have radiotherapy as part of your treatment that affects the womb and may stop the ovaries from working

Occasionally it’s possible to move the ovaries out of the treatment area before radiotherapy begins, to try to avoid early menopause, and this is done by keyhole (laparoscopic) surgery.

The eggs or some ovarian tissue can be removed and frozen before starting treatment, and the eggs could then be used for fertility treatment and surrogate pregnancy afterward, but this is very rare.

The good news is that if your cancer is limited to small growths in the cervix, you may have to have conization or cone biopsy, and with this type of treatment you will be able to conceive afterwards. You’ll probably need to wait 6-12 months before you try to conceive, but there is a chance you may have a higher risk of miscarriage or infertility struggle. This is due to potential changes to and scarring of the cervix after you get this treatment.

In any case, navigating through cancer is not an easy task and will bring up to the surface all kinds of negative emotions which you have to deal with. Your mental health has to be steady and strong to survive through this, especially if treating cancer may lead to not being able to conceive. Trusting your doctor and being well-informed about your options is crucial. If you are experiencing infertility struggles and/or coming out of cancer treatment we have created a safe space for you to share your feelings and find support and strength from others that may deal with similar issues.

DM us or book a free call to answer all your inquiries.