Women's Health

Cervical cancer

Persistent high-risk HPV infection can cause cervical precancer and invasive cancer; England's screening programme uses primary hrHPV testing with cytology triage, while symptoms or a suspicious cervix require direct clinical assessment and specialist staging.

In a nutshell

Persistent high-risk HPV can cause cervical precancer and invasive cancer. In England, screening uses primary hrHPV testing with cytology triage: hrHPV-negative results return to routine recall, while persistent hrHPV or abnormal cytology leads to surveillance or colposcopy. Symptoms and a suspicious cervix require clinical assessment and should not be dismissed by a negative screening result.

Classic presentation

Postcoital, intermenstrual or postmenopausal bleeding, persistent abnormal discharge or an abnormal-looking cervix; CIN is usually asymptomatic and found through screening.

Key points

Persistent high-risk HPV, rather than a single transient HPV infection, drives most cervical precancer and cancer.
Cervical screening is prevention, not a diagnostic test for symptomatic bleeding or a suspicious cervix.
England uses primary hrHPV testing with cytology triage; hrHPV-positive and abnormal cytology leads to colposcopy, while persistent hrHPV with negative cytology is retested at 12 months and referred after a third positive result.
High-grade CIN requires colposcopic assessment and treatment in an appropriately equipped service; do not ablate when invasion or glandular disease is suspected.
After CIN treatment, use the hrHPV test-of-cure pathway at 6 months and continue the required follow-up.
Early invasive disease may be treated surgically; locally advanced disease usually needs chemoradiotherapy and brachytherapy in a specialist MDT.
NICE TA939 recommends pembrolizumab plus chemotherapy with or without bevacizumab for selected PD-L1-positive persistent, recurrent or metastatic disease; current NHS England CDF access for pembrolizumab with chemoradiotherapy in selected untreated stage 3 to 4A disease must not be confused with final NICE guidance.
HPV vaccination reduces risk but does not remove the need for cervical screening.

First-line investigation

Clinical speculum assessment for symptoms; if screening is appropriate, primary hrHPV testing with cytology triage; colposcopy and biopsy for abnormal screening or a suspicious cervix.

Management

Escalate a suspicious cervix or unstable bleeding

Examine symptoms, arrange urgent specialist assessment for a cervix that looks malignant and manage heavy bleeding or obstruction as an emergency; do not rely on screening to exclude cancer.^4,6

Separate screening from diagnosis

For eligible asymptomatic screening participants, use primary hrHPV testing with cytology triage; persistent hrHPV or abnormal cytology leads to the current surveillance and colposcopy pathway.^1,3
Use colposcopy with biopsy or appropriate excision to diagnose CIN, CGIN or invasion, then stage confirmed invasive cancer with specialist examination and selected MRI, CT or PET-CT imaging.^5,6

Prevent HPV disease and support the whole person

Offer and promote HPV vaccination according to UKHSA guidance, continue cervical screening after vaccination, and address smoking, immunosuppression, fertility, sexual health, psychosocial needs and treatment fitness.^2,10,1

Match treatment to histology and FIGO stage

Treat high-grade CIN or CGIN through colposcopy and specialist pathways; use surgery for selected early invasive disease and chemoradiotherapy with brachytherapy for most locally advanced disease.^5,7,11
For recurrent, persistent or metastatic PD-L1-positive disease, consider the NICE TA939 pembrolizumab pathway; for selected untreated stage 3 to 4A disease, check current NHS England CDF and live NICE appraisal status before describing pembrolizumab with chemoradiotherapy as routine care.^14,12,13

Complete test-of-cure and specialist surveillance

After CIN treatment, perform the hrHPV test of cure at 6 months and follow the result-dependent recall or colposcopy pathway; after invasive cancer, follow the specialist plan and safety-net recurrent bleeding, pain, urinary or bowel symptoms and treatment toxicity.^5,3,7

Exam traps

Do not use a negative cervical screening result to rule out cancer in someone with persistent symptoms or a suspicious cervix.
Do not refer every episode of postcoital bleeding automatically through a 2-week-wait pathway without examination; NICE specifically bases cervical referral on a cervix whose appearance is consistent with cancer.
Cytology describes a screening sample; CIN is a histological diagnosis from tissue.
Do not treat CIN with destructive therapy if invasion, glandular abnormality, an inadequately visualised transformation zone or another exclusion criterion is present.
Do not describe the June 2026 pembrolizumab chemoradiotherapy appraisal as final NICE guidance; check the live NICE and NHS England position.

Illustrations

HPV E6/E7 mechanism of carcinogenesisDiagram showing HPV E6 and E7 effects on tumour-suppressor pathways in cervical epithelium, with a clear distinction between persistent infection and progression to precancer.PassFinals · original

From HPV persistence to invasive cervical cancerPathway diagram showing persistent high-risk HPV, CIN and invasive disease, with screening and colposcopy interrupting progression without implying a fixed timetable for every person.PassFinals · original

England cervical screening pathwayFlowchart showing primary hrHPV testing, cytology triage, 12-month repeat testing for persistent HPV with negative cytology and colposcopy referral for abnormal cytology or persistent HPV.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.