Symptoms and signs of cervical cancer

Initially, complaints occur only rarely. Sometimes a sweet-smelling discharge and spotting (especially after sexual contact) can be the first signs of cervical cancer. In the advanced stage, the tumour spreads further into the wall of the cervix as well as into the vagina, pelvic wall, rectum, and the connective tissue holding apparatus of the uterus in the pelvis (the so-called parametrias).

Metastases of the tumor can initially spread via the lymphatic system, and later also by ingrowth into blood vessels in the liver, brain, lungs and bones (so-called hematogenic metastasis, i.e. metastasis via the bloodstream), resulting in severe pain. From the age of 20 onwards, annual preventive medical check-ups are recommended, as infection with the cancer-causing virus can occur very early. The detection of precancerous stages is possible by means of smear tests. The cells thus obtained are stained for visualization. The evaluation is carried out in classes PAP (Papanicolaou) from I to V, according to a normal finding up to cell alterations, the urgent suspicion of tumor prove with necessity of immediate clarification by taking a tissue sample.

Classification according to Papanicolaou

PAP I – Normal cell pictureThe findings are normal, there are no abnormalities, control after one year as part of the cancer screening examination.
The findings are normal, there are no abnormalities, control after one year as part of the early cancer detection examination.
PAP II – Inflammatory and metaplastic changesThe cell changes are unsuspicious, mostly caused by bacteria or other germs, if necessary examination after 3 months and a possible treatment of the inflammation.
The cell changes are unsuspicious, mostly caused by bacteria or other germs, if necessary examination after 3 months and a possible treatment of the inflammation.
PAP III – Severe inflammatory or degenerative changes, an assessment as to whether the changes are malignant is not possible with certaintyThe findings are unclear; if necessary, antibiotic or hormonal treatment; short-term control after approx. 2 weeks; if Pap III persists, a histological clarification (histology) is important
The findings are unclear; if necessary antibiotic or hormonal treatment; short-term control after approx. 2 weeks; if Pap III persists, a histological clarification (histology) is important.
PAP III D – cells show slightly to moderately atypical cell alterations.
The findings are unclear; mostly this alteration is related to the common HPV – infection. Control after 3 months is sufficient, histological clarification is only necessary in case of repeated occurrence.
The findings are unclear; mostly this change is related to the common HPV infection. Control after 3 months is sufficient, histological clarification is only necessary in case of repeated occurrence.
PAP IV a – severe cell dysplasia or a carcinoma in situ (precancerous stage)Fine tissue (histological) clarification by means of curettage (scraping) and colonoscopy/hysteroscopy.
Fine tissue (histological) clarification by means of curettage (scraping) and colonoscopy/hysteroscopy.
PAP IV b – severe cell dysplasia or a carcinoma in situ (early stage of cancer), cells of a malignant cancer cannot be ruled outRequires fine tissue (histological) clarification by conisation (see below) or biopsy (obtaining a tissue sample), therapy depending on the findings and family planning of the patient
Requires fine tissue (histological) clarification by conisation (see below) or biopsy (obtaining a tissue sample), therapy depending on the findings and the patient’s family planning.
PAP V – Cells of a presumably malignant cancer (malignant tumor), tumor is clearly malignantRequire fine tissue (histological) clarification by conisation (see below) or biopsy (obtaining a tissue sample).
Therapy: removal of the uterus (hysterectomy).
Requires histological clarification by conisation (see below) or biopsy (obtaining a tissue sample). Therapy: removal of the uterus (hysterectomy).
The findings are normal, there are no abnormalities, control after one year as part of the early cancer detection examination.
The cell changes are unsuspicious, mostly caused by bacteria or other germs, if necessary examination after 3 months and a possible treatment of the inflammation.
The findings are unclear; if necessary antibiotic or hormonal treatment; short-term control after approx. 2 weeks; if Pap III persists, a histological clarification (histology) is important.
The findings are unclear; mostly this change is related to the common HPV infection.
Control after 3 months is sufficient, histological clarification is only necessary in case of repeated occurrence.
Fine tissue (histological) clarification by means of curettage (scraping) and colonoscopy/hysteroscopy.
Requires fine tissue (histological) clarification by conisation (see below) or biopsy (obtaining a tissue sample), therapy depending on the findings and the patient’s family planning.
Requires histological clarification by conisation (see below) or biopsy (obtaining a tissue sample). Therapy: removal of the uterus (hysterectomy).

During the gynecological examination, the cervix is accessible by means of colposcopy (literally: “reflection of the vagina” from the Greek kolpo = vagina, skopie = peeking). This diagnostic method, which serves the early detection of cervical cancer, was introduced in the 1920s by Hans Hinselmann.

The cervix is viewed with a special microscope (colposcope) under optimal illumination with a magnification of six to twenty times. The acetic acid sample can be used to visualize precancerous lesions (so-called precanceroses) and mucosal changes associated with an increased risk of cancer (e.g. the transformation of the uterine mucosa into vaginal mucosa as a result of recurrent inflammation, known as metaplasia; to a certain extent, however, this transformation of the mucosa is also normal and can be detected in all women after puberty). Since, however, normal mucosa is also stained by the acetic acid sample, the dark brown to black staining of exclusively healthy cells, which takes place within the scope of the so-called Schiller iodine sample, is helpful in differentiating healthy from diseased tissue.

The basis of this detection is the chemical reaction of the glycogen contained in normal cells (a giant molecule consisting of several thousand sugar components serving as storage) with iodine to form a brown reaction product. Pathologically altered mucosa (so-called metaplastic mucosa or precancerous lesions caused by inflammation), on the other hand, contains little glycogen and therefore stains only slightly or not at all. The colposcope itself is not inserted into the vagina, but positioned in front of it.

To unfold the vaginal walls, the gynecologist uses a speculum (lat. : hand mirror; for insertion into natural body cavities, it is tubular, funnel-shaped or spatula-shaped). Using special small forceps, it is possible to remove small pieces of tissue and examine them under a microscope.

In addition to mere observation, a colposcope also allows the taking of photos and video recordings for documentation purposes. The aim of colposcopy is to classify the degree of severity when a pathological change is detected. Decisive factors here include color, surface condition, and the stainability of the suspicious tissue portion through iodine.

Superficial white staining of the mucosa (known as leukoplakia) may be harmless or indicate an underlying precancerous stage. Red spots or ridges (“mosaic”) correspond to vessels reaching the surface, and are always suspicious of malignant changes. So far, a positive effect in cancer screening has not been proven.However, colposcopy seems to us to be a very sensible precautionary measure. Colposcopy is not included in the scope of services of the GKV (statutory health insurance).