This guide is designed for healthcare professionals, offering essential knowledge for effective public education on cervical cancer prevention.
Secondary prevention: cervical cancer screening and precancerous lesion management
Should asymptomatic individuals be screened for cervical cancer?
Cervical cancer is the most common malignancy of the female reproductive organs, primarily caused by persistent HR-HPV infection. It can take 10 to 20 years or more for HPV infection to progress to cervical cancer, often without symptoms. Regular screening allows early detection and treatment of precancerous lesions to prevent progression.
What are the methods for cervical cancer screening?
Screening is recommended for sexually active women at an appropriate age to detect potential cervical precancer or cancer. Screening methods include HR-HPV testing, cytology testing or a combination of both.
When should cervical cancer screening begin?
The recommended starting age for cervical cancer screening in the general female population is 25 to 30 years.16 National cancer screening policies organise screenings for women in this age group.
When can cervical cancer screening be discontinued??
Women over the age of 65 who have had documented adequate negative prior screening in the past may terminate screening (ie, three consecutive normal cytology screenings or two consecutive negative HPV tests or two consecutive negative co-tests within the past ten years, with the most recent test occurring within the past 5 years) and no high-risk factors, such as history of CIN2+and related treatments. Women who have undergone total hysterectomy for benign conditions and have no history of cervical precancerous lesions do not require screening.16
How often should cervical cancer screening be performed?
The screening interval depends on the method used. Women of appropriate age should be screened every 3–5 years. Those aged 35–64 are encouraged to participate in regular screenings. For women at high risk, such as those with HIV, screening should start earlier and occur more frequently.16 17
What to do if the screening is abnormal?
Women with abnormal screening results, including positive HPV tests, should undergo further evaluation per medical guidance, with colposcopy if necessary.
What is HPV and what types does it include?
HPV is a double-stranded DNA virus, categorised into high-risk and low-risk types based on carcinogenicity. High-risk types, such as HPV 16 and HPV 18, account for 70% of cervical cancers, while HPV 6 and HPV 11, considered low-risk, are linked to 90% of genital warts.18
Who are the high-risk populations for HPV infection?
High-risk groups include19 20 individuals with high-risk sexual behaviours (eg, early sexual debut, multiple partners or unprotected sex); individuals with compromised immunity, such as those with HIV, post-transplant patients, those with autoimmune diseases (eg, lupus or Sjögren’s syndrome) or those on prolonged immunosuppressant therapy; and individuals with other sexually transmitted infections (STIs), such as herpes simplex or gonorrhoea. High-risk populations should begin screening earlier.17
How is HPV infected?
HPV infection can occur through the following routes: sexual contact is the primary mode of HPV transmission; other indirect contact and mother-to-child transmission may also cause HPV infection.21 22
Do sexual partners need to be tested for HPV?
Most men with HPV are asymptomatic and do not require screening. However, men with risk factors—such as foreskin abnormalities, genital ulcers, growths, HIV infection or men who have sex with men—have higher infection rates and should seek evaluation at specialised clinics.23
What to do if the HPV test is positive?
A positive HPV test does not equate to cervical precancer or cancer. Follow-up with colposcopy is necessary for abnormal screening results, and any precancerous lesions detected should be treated promptly.16
Should persistent HPV infection without regression be intervened?
Persistent HPV infection refers to the continued presence of the same HPV type for 6–12 months.7 24 Persistent HR-HPV requires a thorough examination of the cervix, vagina, vulva and perianal area for lesions. In the absence of abnormalities, regular follow-ups are recommended. Factors such as age influence the likelihood of HPV clearance, with older age associated with lower clearance rates.25
Why do HPV types change?
HPV infections can vary due to factors like immune response, concurrent multiple-type infections and testing methods. The same individual may be infected with one or more HPV types at the same time.26 Some latently infected HPVs cannot be detected, or the HPV positivity detected may be different due to different detection methods. Although type change slightly reduces the risk of precancerous lesions compared with persistent same-type infection, it remains higher than with HPV-negative results. The short-term CIN3+ risk in such cases is around 1.7–20%.27
Does the risk increase with more HPV types?
HPV types can be divided into high-risk and low-risk types. While high-risk HPV types can lead to cervical cancer, low-risk types generally do not. Although many women will encounter HPV during their lives, most will clear it naturally. HPV testing aims to identify those at higher risk for cervical precancer or early cancer, with single-type infection predominant among Chinese women. There is no significant correlation between the number of HPV types and the risk of cancer.28
Does a positive HPV 16 or 18 result indicate cancer?
HPV 16 and HPV 18 are closely linked to cervical cancer,29 yet a positive result does not mean cancer is present. It indicates an infection, increasing the risk for precancerous lesions, and should lead to a referral for a colposcopy for further assessment.
Can condoms prevent HPV infection?
Condoms could provide partial protection, as HPV can infect areas not covered. They do offer some protection against other STIs, so using condoms is advised if not attempting pregnancy.30
What is a colposcopy?
A colposcopy, using a magnifying tool, examines the cervix, vagina, vulva and perianal area for lesions or tumours related to HR-HPV.31
What happens during a colposcopy?
Following an inspection similar to a gynaecological exam, 3–5% acetic acid is applied to highlight areas needing attention. If needed, an iodine solution and biopsies may be used for further lesion assessment.32 These biopsies are used for pathological examination to confirm the diagnosis.32
What should be noted before colposcopy?
Avoid scheduling during menstruation and refrain from sexual activity, douching and medication 24 hours prior. Follow institutional requirements for related tests.
Is a biopsy painful?
Cervical biopsies are generally painless, not typically requiring anaesthesia due to the cervix’s low sensitivity to pain. Small sample sizes (approx. 3 mm) are taken. There may be some discomfort during the biopsy, but it is usually tolerated without anaesthesia.33
How to care after colposcopy?
If gauze is placed in the vagina to stop bleeding after the biopsy, remove it within 24 hours. If the bleeding exceeds the menstrual volume, the patient should go to the hospital for treatment. The patient should avoid sex, baths and strenuous activity for 2 weeks. Follow-up with biopsy results at the scheduled time.34
What are cervical precancers, and how are they treated?
High-grade cervical lesions confirmed via histopathology following biopsy are cervical precancerous lesions, including cervical intraepithelial neoplasia grade 2 and 3 (CIN2 and CIN3) and adenocarcinoma in situ (AIS). Most precancerous lesions require treatment. The most common treatments for cervical precancerous lesions are excisional treatment and ablative treatment. The former includes loop electrosurgical excision procedure or cold knife cervical conisation, while the latter includes laser or cryotherapy.35
How to treat cervical precancerous lesions?
Young patients with CIN2: lesions may self-resolve. Cytology and colposcopy follow-ups are suggested every 6 months over 24 months.
CIN3 patients: treatment is advised due to higher progression risk3 to prevent missed diagnosis of early cervical cancer.
AIS patients: excision is necessary, as lesions are commonly hidden in crypts and have a characteristic skip growth pattern.35
What should be noted before a cervical conisation?
Before cervical conisation, preoperative examinations should be completed. For patients with acute genital inflammation, surgery should be performed following recovery. If there are other diseases, surgery should be performed after risk assessment and risk control. Surgery should be performed 3–7 days post-menstruation, and sexual intercourse is prohibited for 72 hours prior to surgery.
Can surgery excision treat HPV infection?
Cervical conisation and hysterectomy are treatments for cervical precancerous lesions and uterine diseases, not for HPV infection. Because HPV infection is not limited to the cervix and may be combined with infection of the vaginal wall, surgery can only remove cervical lesions but cannot eliminate HPV. Patients with a history of HPV-related lesions have an increased probability of recurrence and progression. Post-surgery, regular co-test (HPV and cytology screenings) are essential.35
What should be noted after a cervical conisation?
After cervical conisation, take medications as instructed. Avoid sex and heavy activities for 1 month. There may be a small amount of vaginal discharge, vaginal bleeding and low fever (<37.5°C) after surgery. Follow-up is required if severe bleeding, discharge or high fever occurs. Schedule a hospital follow-up in a month. If cervical stenosis and adhesions occur after surgery, they should be treated as soon as possible.36
What are the complications after cervical conisation?
Recovery is usually smooth, though risks include infection, bleeding, cervical adhesions and cervical stenosis. There may also be risks for future pregnancies, such as miscarriage, preterm birth, premature rupture of membranes and low birth weight in newborns due to decreased cervical function.35
Does cervical conisation require follow-up？
Yes, follow-up is essential after cervical conisation. HR-HPV testing or co-testing should be conducted 6 months post-surgery. If any results are abnormal, a colposcopy is recommended. For normal re-examination results, HR-HPV-based testing should continue every 12 months for 3 years. If tests remain normal over three consecutive years, the interval can be extended to every 3 years for a minimum of 25 years.35
If a cervical biopsy shows CIN3, can a hysterectomy be performed immediately?
No, a hysterectomy should not be performed solely on the basis of a CIN3 result, as early invasive cervical cancer cannot be completely ruled out. Only cervical conisation followed by a detailed pathology examination can confirm a diagnosis. Total hysterectomy should be considered only when conisation is contraindicated.35
Tertiary prevention: key points on cervical cancer treatment and follow-up
What is cervical cancer?
Cervical cancer is a malignant tumour arising in the epithelial cells of the cervix or endocervical canal. Approximately 80% of cervical cancers are squamous cell carcinomas, 15–20% are adenocarcinomas, and the remainder are rare and special types.37
What are the symptoms of cervical cancer?
Early cervical cancer often presents no symptoms. However, patients may seek medical care due to post-coital bleeding. Some elderly individuals may experience irregular vaginal bleeding, increased discharge or foul-smelling odour. Advanced-stage patients may exhibit symptoms such as leg swelling, urinary issues from bladder compression or bowel changes from rectal compression. Pelvic pain, similar to inflammation, is also possible. The earlier it is detected, the higher the survival rate and the better the prognosis.38
How is cervical cancer treated?
Treatment options for cervical cancer include surgery, radiation therapy, chemotherapy, targeted therapy and immunotherapy.39 Interventional procedures and particle implantation may also benefit certain patients. Doctors recommend treatment based on the tumour stage and the patient’s and family’s preferences.
What should be done if cervical cancer is discovered during pregnancy?
Cervical cancer diagnosed during pregnancy requires personalised treatment, considering the cancer stage, gestational age and the patient’s wishes regarding pregnancy.
For stages IA2 and above before 22 weeks of pregnancy: radical surgery may follow pregnancy termination; fertility-preserving surgery may be an option for some.
For stage IA1 cases with intent to continue pregnancy: expectant management, involving cytology and colposcopy every 8–12 weeks, is common. If no progression occurs, treatment may be deferred until after delivery.
For more advanced stages: neoadjuvant chemotherapy may allow pregnancy continuation until fetal maturity, with platinum-based chemotherapy generally administered before 34 weeks.40
What should be noted before cervical cancer surgery?
Pre-surgical preparations include extensive evaluations to assess cancer stage, physical health and surgical indications. Routine blood tests (eg, complete blood count, liver and kidney function), tumour markers (eg, SCC, CA125, CA199, CEA), electrocardiograms and imaging studies are conducted. Patients must fast the night before surgery and inform the doctor of any medications, particularly anticoagulants or blood pressure drugs, as these may need to be adjusted based on medical advice.
What should be noted after cervical cancer surgery?
Postoperative care includes rest and avoiding strenuous activities or heavy lifting to promote wound healing. A balanced diet, avoiding spicy foods and incorporating protein- and vitamin-rich foods are recommended to support recovery. Further treatments like radiotherapy and chemotherapy may be advised based on pathological findings. Regular follow-ups with the healthcare provider are necessary to monitor recovery and check for recurrence.
Is chemotherapy or radiotherapy needed after cervical cancer surgery?
The need for chemotherapy or radiotherapy depends on the pathological findings post-surgery. Patients with high-risk factors require pelvic radiotherapy and concurrent cisplatin chemotherapy. Close margins (<5 mm) or limited surgical scope also present potential recurrence risks.41 Treatment planning should involve multidisciplinary discussions with surgeons and radiotherapists. Additionally, highly malignant tumours (poor differentiation or unfavourable pathology) may impact prognosis, requiring tailored treatment decisions based on individual patient circumstances.
How often should follow-up exams be conducted after cervical cancer surgery?
Patients who have undergone cervical cancer treatment require lifelong follow-up to detect recurrences early. Approximately 80% of recurrences occur within 2 years post-surgery. Follow-up exams should be scheduled every 3 months during the first year, every 3–6 months in the second year and every 6 months between the third and fifth years. Afterwards, follow-ups are recommended annually. If a recurrence is detected, treatment should begin promptly, and the follow-up interval should be adjusted as needed.42
Science education for different female/male
Key points of popular science for girls aged 9–14
HPV vaccination: it is best to vaccinate against HPV before sexual activity begins. For girls aged 9 to 14, a two-dose HPV vaccine series is recommended with a 1 year interval (at least 6 months). For those immunocompromised populations, a three-dose schedule is preferable, though at least two doses with a 6 month gap are recommended.10
Safe sexual practices: adolescents have developing reproductive systems and should avoid premature sexual activity. Those who are sexually active are advised to get the HPV vaccine as early as possible and to consistently use condoms to lower the risk of HPV and other STIs. In cases of unprotected intercourse, seeing a healthcare provider within 24 hours for emergency contraception is recommended.
Good hygiene habits: daily vulvar washing with clean water, regular underwear changes and the use of sanitary menstrual products are essential. If any discomfort or unusual discharge occurs, seek medical attention promptly. To support reproductive health, avoid tobacco and drug use.
Education and awareness: encourage young people to build self-protection skills, helping them understand and recognise the signs of sexual harassment and assault. They should know they can seek help to avoid physical and emotional harm.
Key education points for women aged 15–26
HPV vaccination for 15–26 year-olds: women who have not received the HPV vaccine should start the three-dose vaccination series. Those who have not completed the vaccination series should do so within a year, and no HPV testing is required before vaccination.
Practise safe sex: consistently using condoms lowers the risk of HPV and other STIs. Other contraceptive methods can also help prevent unintended pregnancies.
Self-protection awareness: be vigilant against sexual harassment and assault. In cases of assault or unprotected intercourse, seek timely medical help and take steps to prevent unwanted pregnancy-related complications.
Cervical cancer screening for women aged 15–26:
For average-risk women, cervical cancer screening is not recommended before age 25.
For those with HIV or compromised immunity, screening should start at age 21 with annual cytology exams. After three consecutive normal results, the interval can extend to once every 3 years.
Women with high-risk behaviours (early sexual activity, multiple partners, history of STIs) should have screening within 1 year of initiating sexual activity and consider shorter screening intervals.16
Key education points for women aged 27–45
Cervical cancer screening for ages 27–45
Women in this age group, particularly those with a sexual history, should undergo regular screening to detect and manage cervical precancerous lesions and early cancer. Screening options include HPV testing every 5 years or cytology every 3 years, depending on personal and financial circumstances.17
HPV vaccination for ages 27–45
While HPV vaccination is most effective before sexual debut, it still provides protection for sexually active women. In China, women aged 27–45 can choose from bivalent, quadrivalent or nonavalent HPV vaccines.
Key education points for women over 45
Cervical cancer prevention and management for ages 46–64
While HPV vaccination is typically not available after age 45, regular cervical cancer screening remains crucial, especially for those who have not been screened previously. Cervical cancer incidence peaks between ages 50 and 55.38
Postmenopausal women may experience an imbalance in vaginal microecology, leading to decreased immunity and higher rates of persistent HPV infection.
For those who have had documented adequate negative prior screening in the past, screening may be discontinued after age 65.1
Do women aged 65 and above still need cervical cancer screening?
Women over 65 who have not been adequately screened in the past decade should continue with screening.17 For elderly women with significant vaginal and cervical atrophy, local oestrogen preparations may improve the sampling process and diagnostic accuracy if there are no contraindications to oestrogen use.
Key education points for pregnant women:
What should be done if pregnancy is discovered after receiving an HPV vaccine?
If pregnancy is discovered after receiving the preventive vaccine, pause vaccination until after delivery to complete any remaining doses. If the vaccination series has already been completed, there is no need to consider terminating the pregnancy due to vaccination.
Is cervical cancer screening necessary during pregnancy?
Yes, cervical cancer screening is important during pregnancy, mainly to detect cervical cancer. Screening is advised for pregnant women who:
Have not had regular or prior screenings.
Need a routine follow-up screening, which should be done either during pre-pregnancy exams or the first prenatal visit, using single cytology or co-testing.17
Under what conditions during pregnancy should a colposcopy be performed?
Colposcopy may be recommended in pregnancy to detect or rule out cervical cancer under these conditions:
Unexplained vaginal bleeding, post-intercourse bleeding, visible cervical mass or abnormalities detected through a physical or pelvic exam.
Screening results indicate HPV positivity with abnormal cytology.33
Is colposcopy safe during pregnancy, and when is the best time to perform it?
Colposcopy is safe throughout pregnancy, but it is best conducted in the first or second trimester. If early colposcopy cannot fully assess the transformation zone and lesions, it may be repeated after 20 weeks.43
What should be noted during a colposcopy examination during pregnancy?
Before the procedure, ensure that the patient has given informed consent. An experienced colposcopist should perform the examination. Cervical biopsy during pregnancy is safe, but endocervical curettage is prohibited.43
Does CIN2 or CIN3 diagnosed during pregnancy require treatment?
Cervical precancerous lesions (CIN2, CIN3) diagnosed during pregnancy generally do not require immediate treatment, as these lesions rarely progress to cancer during pregnancy and often regress postpartum. Therefore, for CIN2 and CIN3 during pregnancy, cytology or colposcopy should be performed every 12 weeks to assess whether CIN2 or CIN3 progresses. After delivery, further review and appropriate treatment should be carried out.43
Impact of HPV infection on pregnancy and fetal health
Most studies suggest that HPV infection does not affect the ability to conceive,44 miscarriage rates, preterm birth or fetal development.45 Thus, HPV infection during pregnancy should not be a cause for concern.
Does HPV infection require a caesarean section?
Caesarean section is not typically recommended to prevent neonatal HPV infection,46 as it does not fully protect against transmission. Delivery methods should be based on obstetric needs. However, if large or multiple genital warts obstruct the birth canal, caesarean delivery may be considered.
Is HPV vaccination safe during breastfeeding?
Since some medications can be passed through breast milk and safety data on HPV vaccination in breastfeeding women is limited, HPV vaccination is advised after breastfeeding completed.10
Key education points for individuals with immunocompromised
How should immunocompromised populations be screened for cervical cancer?
Immunocompromised individuals include those with genetic or acquired immune deficiencies, such as primary immunodeficiency disorders, HIV-positive individuals, solid organ or haematopoietic stem cell transplant recipients, cancer patients undergoing chemotherapy, those receiving glucocorticoid or other immunosuppressive therapies for autoimmune diseases,47 who have a higher risk of cervical cancer and should undergo more frequent cervical cancer screenings. Screening intervals should be shortened accordingly and follow similar protocols to those used for HIV-positive individuals.17
Are HIV-positive individuals at a higher risk for HPV and cervical cancer?
HIV-positive women have a higher incidence of HR-HPV infection, cervical intraepithelial lesions and cervical cancer. HPV-positive individuals have a doubled risk of HIV infection.48 Women with HIV have a 2 to 22 times higher incidence of cervical cancer compared with HIV-negative women.49
Can immunocompromised individuals receive the HPV vaccine?
Yes, HPV vaccination is recommended for immunocompromised populations, including HIV-positive individuals and those on long-term immunosuppressive therapies post-transplant. Vaccination prioritisation is often given to HIV-positive patients.10
Key education points for males
Can men be infected with HPV?
Yes, men can be infected with HPV, which can affect the penis, scrotum and perineal/perianal areas. The global average HPV infection rate among men is approximately 31%, with 90% of these infections being transient and 10% potentially developing into persistent infections.50 Persistent HPV infections in men can lead to anal, penile and oropharyngeal cancers, as well as genital warts, primarily caused by HPV types 6 and 11.51 52 Preventing HPV infection in men is essential for reducing HPV transmission to women.
Who are the high-risk groups for HPV infection in men?
High-risk groups for HPV infection in men include (1) individuals with multiple sexual partners; (2) sexual partners who are infected with HPV; (3) individuals with autoimmune diseases, immunocompromised or who are immunosuppressed; (4) men who have sex with men; and (5) individuals with other sexually transmitted infections.53 Some studies suggest that circumcised men may have a lower risk of genital HPV infection.54
What are the routes of HPV infection in men?
The primary route of HPV infection in men is through sexual intercourse, which includes: male-female intercourse, male-male intercourse, hand-genital contact, and oral-genital contact. There are also a few non-sexual transmission routes.55
4. Where are HPV infection tests performed in men?
HPV testing in men can be conducted at various sites, including the penis, glans penis (coronal sulcus and urethral opening), scrotum, perianal area and anal canal. However, HPV testing in men can be challenging and may result in false-negative results.
Can men receive HPV vaccines?
In some countries, men aged 9 to 45 can receive the nonavalent HPV vaccine.56 On 8 January 2025, the quadrivalent HPV vaccine was approved in China for vaccination in males aged 9 to 26.
In summary, cervical cancer is a serious health threat for women in China. Promoting public awareness, especially among women, is crucial in the prevention and treatment of cervical cancer. Women should take responsibility for their own health. The foundation of effective public education is the scientific accuracy of information. This guide aims to equip healthcare professionals with essential knowledge and methods for three-level prevention of cervical cancer, thereby aiding in the promotion of cervical cancer awareness and treatment.
