Dr Thomas Stuttaford

I am glad to hear that you have regular checks. Vigilance, coupled with a wary, almost pessimistic, approach is the basis of good, safe treatment. Obviously extreme caution such as this involves the patient in some nuisance and discomfort, and the medical services in cost. So far as the individual patient and their doctor are concerned, the cost should be left for the accountants and the politicians. When as a doctor I see a patient my only concern in my opinion should be her welfare, and what will give her the best chance of long term health. If the Department of Health want to take a risk with her life, even a tiny risk, to save money that is up to them and their decision. Medical excuses shouldn’t be used to explain cost cutting.

1. Is all cervical cancer caused by HPV? Probably. It has shown in a variety of international studies that in between 95 and 98 per cent of the patients HPV can be detected in the specimens. The obvious suspicion is that in those in which it isn’t detected there has been a failure in the system of detection rather than a true negative result.

2. Eighty per cent of women are known to be infected by HPV at some time in their lives, but normally the immune system manages to overcome any infection before the woman’s cervical cells have developed a reactionary malignant change. When we talk about other causes of carcinoma of the cervix what we should consider is why in some people, a small minority, the virus continues to survive on the cervix and eventually give rise to cervical cancer. It is accepted therefore that there must be other factors that encourage the virus to survive in some women. These include smoking, various conditions that affect the immune system, probably a genetic (ie. familial) tendency and a large number of different sexual partners. Frequent sex with the same partner is not a risk factor. Despite these risk factors, most women to whom they apply will have no trouble at all. They too will pick up HPV but their immune system will conquer it. The likelihood of the virus causing malignant changes if it survives on the cervix is also dependent on the oncogene activity in the virus. There are various systems for estimating HPV E6/E7 oncogene activity in the strain of virus. As well as knowing the type of virus, it may therefore be useful to know about its HPV E6/E7 oncogene activity. There are nearly one hundred different form sof wart virus (HPV) that affect humans. Some will give rise to quite disgusting looking warts, but are otherwise harmless. The HPV types 16, 18, 31, 33 and 45 regularly cause difficulties. It is when one of these viruses persist that HPV E6 E7 oncogene activity may be of value in estimating the chances of trouble ahead.

3. I suspect that all HPV of the cervix is sexually transmitted but the nature of the sexual activity may sometimes fall short of what is known as “full sex”. HPV induced problems can also occasionally be found on the penis and perianally.

4. It varies. I have seen carcinoma of the cervix in very young women and in others who haven’t had sex for years and years. In general it is always described as a cancer that doesn’t usually develop quickly so that there is plenty of time to observe the cell changes and to take action in time to prevent potential fatal malignancy. The objective of the cervical smear is not to treat cancer, but to prevent it.

5. The changes in the cervix are usually classified as being CIN1, CIN2, CIN3, carcinoma in situ and invasive carcinoma. Pathologists may use a more detailed description but all demonstrate that there are many degrees of non-malignant cell changes before the lesion becomes malignant.

I have the HPV infection and I am having a smear test and colposcopy every four months. Twice I had CIN3, which was removed. Please let me know what the difference is between screening and colposcopy - and what is an HPV typing? Name and address withheld

The colposcope is like a combination of a camera and a microscope that slides into a woman’s vagina as easily as the instruments used when having a smear. The doctor looking down the colposcope is therefore able to look at a woman’s cervix as if it was under the microscope. He or she is able to take biopsies from any area that looks suspicious. Before examining the cervix it is usual to paint it with a solution that colours any potentially dodgy area white. The whiter the area, the more dodgy the lesion is likely to be.

Colposcopy always includes screening but not all screening includes colposcopy. In most cervical screening the doctor will collect cells from the cervix and have a general look around. The cervical cells may be collected with a spatula or with a fine brush. In either event the results from the scraping, or brushing, are placed in fluid and studied by experts. Only rarely are HPV cultures carried out and even less rarely are they typed. The NHS is not usually willing to identify the type – they think it is too expensive. If you want to find out the type of HPV you can always ask your GP to refer you privately to a gynaecologist who takes an interest in this, and has access to the appropriate path labs. If I was a woman I, like you, would like to know what type of HPV I had and would also like to know about its oncogene activity once, or if this became appropriate.

Twenty years ago, at the age of 27, I had a smear which showed pre-malignant cell changes and HPV virus. I had laser treatment, followed by four years of six monthly colposcopy and smears. I was advised to always have yearly smear tests which I have done. They have been negative for ten years. I have now been turned away from my yearly smear, having had more than three clear tests and told I should have smear tests every 3-5 years. Is this advice correct? Am I being “over screened”? Name and address withheld

This is standard NHS advice and there is good evidence that in the overwhelming number of cases it is safe advice. I am probably over cautious but if I had your history I would still like to have an annual smear (taken by the new brush method not all that new, actually - we have been using it for years), but then I have explained that I am an extravagant pessimist. If this was not done on the NHS I would go privately. Certainly if I had had a new partner, or if my partner had been straying away, in my opinion it would be appropriate for a woman to return to a more frequent test schedule. I don’t think you have been over screened in the past.

I am a 37-year-old single woman and have been celibate for over ten years. Every time I get a call up for a smear test, I have to go back time and time again because they tell me that they have been unable to get a good enough sample. I have had to back every few months over the last four years and still they can’t get one right. Is there any point in having the tests done? Name and address withheld

Several years ago I did some research on reliability of smears and how many were so badly taken as to be worthless. As in many aspects of medicine there were two important factors. The anxiety and tension felt by the woman was one, and the confidence and ability to get the woman to relax was the other.

Not all cervices are equally easy to see. In most cases when the patient is relaxed and the doctor experienced the cervix pops into view as soon as the speculum is inserted. Sometimes the cervix is antiverted (facing forwards) or the woman’s vaginal and leg muscles are held very tight and the procedure is more difficult. Kindliness, experience, and obvious confidence on the part of the doctor and friendliness from the nurses all help. A relaxed atmosphere in the clinic is an enormous advantage. If you have had several negative tests in a row, and if you are HPV negative ten years after your last sexual contact, the chances of developing cancer of the cervix are negligible.

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