Immediate steps. Explain that most abnormal results do not mean cancer, and agree a clear follow up date. Refer within 2 weeks for high grade results, glandular abnormality, possible invasion or any visible suspicious cervical lesion. Treat vaginal infection if found.
Cervical intraepithelial neoplasia 1. Observation: repeat HPV test or cytology and colposcopy at 12 months, because most lesions regress. Treat persistent disease at 24 months or if the transformation zone cannot be assessed. Do not treat on a low grade result alone.
Cervical intraepithelial neoplasia 2 and 3. Treat. Excision of the transformation zone (large loop excision or cold knife) is first line, because it gives histology and margin status. Depth: about 7 to 10 mm for type 1, 10 to 15 mm for type 2 and 15 mm or more for type 3 transformation zones.
Ablation (cryotherapy, thermal ablation, laser) is acceptable only for lesions entirely visible, of limited size and with no suspicion of invasion or glandular disease.
In women under 25 or wishing to preserve fertility, cervical intraepithelial neoplasia 2 can be observed with colposcopy and sampling every 6 months for up to 2 years. Cervical intraepithelial neoplasia 3 is treated.
Local anaesthetic and perioperative care for excision.
- Lidocaine 1% to 2% 5 to 10 mL infiltrated into the cervix (maximum 200 mg of plain lidocaine, 3 mg/kg; maximum 500 mg, 7 mg/kg, if combined with adrenaline).
- Paracetamol 1 g orally every 4 to 6 hours, maximum 4 g daily (3 g daily with chronic alcohol use, malnutrition or hepatic impairment; 15 mg/kg each dose under 50 kg).
- Ibuprofen 400 mg orally every 6 to 8 hours with food, maximum 2.4 g daily. Avoid ibuprofen in peptic ulcer, renal impairment, heart failure and NSAID sensitive asthma.
- Advise that vaginal discharge and light bleeding last up to 4 weeks, and avoid tampons, intercourse and swimming for 4 weeks.
Complications of treatment.
- Secondary haemorrhage (within 2 weeks): treat with pressure, silver nitrate, Monsel paste, suture or packing, and tranexamic acid 1 g orally three times daily for up to 4 days.
- Tranexamic acid renal steps: serum creatinine 120 to 249 micromol/L, 1 g twice daily; 250 to 500 micromol/L, 1 g once daily; over 500 micromol/L, 500 mg once daily. Contraindicated with active thromboembolism.
- Infection: co-amoxiclav 625 mg orally three times daily for 5 days (625 mg twice daily when creatinine clearance is under 30 mL/min). For penicillin allergy, doxycycline 100 mg orally twice daily with metronidazole 400 mg orally twice daily, avoiding doxycycline in pregnancy.
- Cervical stenosis.
- Increased risk of preterm birth with deeper or repeated excisions.
Adenocarcinoma in situ. Cold knife or laser cone excision with negative margins and endocervical sampling. Hysterectomy is advised when childbearing is complete or margins are involved. Fertility sparing management needs close follow up with HPV test and cytology.
Microinvasive and invasive cancer. Multidisciplinary oncology care.
- Early stage disease: cone biopsy, simple or radical hysterectomy or radical trachelectomy with pelvic lymph node assessment.
- Locally advanced disease: external beam radiotherapy with brachytherapy and concurrent cisplatin 40 mg/m2 intravenously once weekly during radiotherapy. Check renal function, full blood count, hearing and electrolytes; reduce or stop for creatinine clearance under 60 mL/min.
- Metastatic disease: platinum based chemotherapy with or without targeted or immune therapy.
Test of cure. After excision or ablation, repeat HPV test (with cytology) at 6 months. A negative test returns the woman to routine recall in many programmes, but women with high grade disease, positive margins or immunosuppression need annual follow up for at least 10 years. A positive HPV test needs colposcopy.
Special groups
- Pregnancy: colposcopy at any gestation is acceptable. Take biopsies only if high grade disease or cancer is suspected, with no endocervical curettage. Do not treat precancer. Reassess 6 to 12 weeks after delivery. Stage and treat invasive cancer with a multidisciplinary team.
- HIV infection: start screening at diagnosis, repeat every 1 to 3 years, ensure antiretroviral therapy with viral suppression, and keep a low threshold for colposcopy.
- Postmenopausal women: vaginal oestrogen before colposcopy improves visibility: oestradiol 10 microgram vaginal tablet nightly for 2 weeks, then twice weekly. Contraindicated with undiagnosed vaginal bleeding, active venous thromboembolism and active liver disease.
- Under 25 years: most women have transient abnormalities, so avoid treatment of low grade disease.
- After hysterectomy for precancer: vaginal vault cytology or HPV test at 6 and 12 months, then annual follow up.
Prevention. HPV vaccination: 2 doses 6 to 12 months apart for girls under 15 years, and 3 doses (0, 1 to 2 and 6 months) for those aged 15 years and over or immunocompromised. Single dose schedules are used in some programmes. Vaccination does not replace screening. Advise smoking cessation.
Continue screening of vaccinated women.
Monitoring. Record the result, plan and recall date in a register. Contact women who miss colposcopy or follow up twice and by more than one method. Audit time to colposcopy and treatment.
Referral and escalation. Refer to colposcopy within 2 weeks for high grade, possible invasive or glandular results, and within 4 to 6 weeks for other results needing colposcopy. Refer to gynaecological oncology within 2 weeks for suspected or confirmed cancer. Refer to a specialist HIV or transplant service for immunosuppressed women.
Admission criteria. Heavy bleeding after treatment, sepsis, obstructed kidneys, and advanced cancer needing urgent care.
Discharge and follow up. Outpatient care with a written plan, recall date and contact number.
Safety netting. Return for heavy bleeding, offensive discharge, fever, severe pain after treatment, or any bleeding between periods, after intercourse or after the menopause.
