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Cervical Cancer

  • What is cervical cancer?

    Cervical cancer stages

    The cervix is part of the female reproductive system. It is a cylinder-shaped neck of tissue connecting the uterus and vagina, positioned at the lowermost portion of the uterus. The cervix produces cervical mucus that changes in consistency during the menstrual cycle to prevent or promote pregnancy.

    Cervical cancer is an abnormal growth that forms in the cervix (the lower part of the womb or uterus). In Singapore, cervical cancer is the 10th most commonly occurring cancer with the 8th highest cancer mortality rate.

    99% of cervical cancer is caused by the human papilloma virus (HPV), which can be spread through sexual activity. HPV is a family of 100 over viruses, of which about 14 strains can cause cancer.

    There are 3 main types of cervical cancer:

    • Squamous cell carcinoma

      This type of cervical cancer forms in the lining of your cervix. It is the most common type, found in up to 90% of cases.
    • Adenocarcinoma

      This form of cervical cancer forms in the cells that produce mucus.
    • Mixed carcinoma

      This has features of both squamous cell carcinoma and adenocarcinoma.
  • Risk factors for cervical cancer

    • Sexual activity

      Being sexually active from a young age and/or having multiple sexual partners increases your risk for cervical cancer, as it exposes you to a higher risk of infection with HPV or any other form of sexually transmitted diseases.

    • Family history of cervical cancer

      You face a higher risk if you have family members who have been diagnosed with cervical cancer.

    • Smoking

      Smoking is a known carcinogen that increases your risk for many types of cancer, including cervical cancer.

    • Oral contraceptives

      Oral contraceptives to prevent pregnancy do not protect against sexually transmitted diseases like HPV. Use of oral contraceptives have been linked to increased risk for cervical cancer.


    Reducing the risk of cervical cancer

    • Cervical cancer screening

      Screening for cervical cancer is known as a Pap smear. In a Pap smear, cells are collected from the cervix and analysed for the presence of cancer cells. It allows earlier detection of cervical cancer, allowing more effective treatment. Another form of screening is a HPV test which looks for the virus which is responsible for most cases of cervical cancer.
    • HPV vaccination

      HPV vaccination helps to protect against cancer-causing HPV strains. It is most effective before a person becomes sexually active. The vaccine can be given to boys (who can transmit HPV) as well as girls.
    • Limit exposure

      Reducing the number of sexual partners and using a condom or other form of barrier protection can reduce your risk.
    • Quit smoking

      You can reduce your risk for cancer and other serious diseases by quitting smoking.
  • Early cervical cancer may have no symptoms. You should see a doctor if you have any of the following symptoms:

    • Abnormal bleeding or discharge from the vagina (after sexual intercourse or between menstrual periods)
    • Pain during sexual intercourse
    • Lower back pain or pelvic pain
    • Late stages symptoms include problems urinating, defecating, or leg swelling
  • Cervical cancer can be diagnosed early through regular screening. If you are sexually active, these tests should be performed every 3 years until the age of 30, and subsequently every 5 years if tests are normal.

    • Pap smear screening

      The Pap smear test is a method of cervical screening used to detect potentially pre-cancerous and cancerous cells in the cervix. It can be performed by a gynaecologist, and usually takes only a few minutes. During a Pap smear, the doctor will use an instrument known as a speculum to hold the walls of the vagina open so that the doctor can see the cervix clearly. A soft brush or spatula is then used to collect sample cells of your cervix. These cells will then be sent to a laboratory to test for cancerous or pre-cancerous properties. You should avoid having sexual intercourse for 24 hours before the test, and you should not have the test performed when you are menstruating.
    • HPV test

      An HPV test detects the presence of HPV and helps to identify the type of HPV. This is important as some HPV strains are more likely to cause cervical cancer. It may be performed at the same time as a Pap smear, or it may be recommended if your Pap smear shows presence of abnormal cells.
    • Colposcopy

      This procedure stains the cells in the cervix with a dye, which are then viewed through a microscope and magnified to check for abnormal cells. This procedure is done if the HPV test or the PAP test is abnormal.

    These screening methods aim to detect precancer of the cervix – known as cervical intraepithelial neoplasia. If detected as a precancer, treatment is usually via a day surgical procedure and does not affect the patient’s fertility, as it involves removing only the diseased part of the cervix.

    However, if there are symptoms, then it is more likely to be an abnormal growth rather than a precancerous condition. For diagnosis, you will need to see a gynaecologist for assessment for any obvious growth on the cervix which may need to be biopsied.

    If there is indeed an early cancer proven on biopsy, then further testing is needed to determine the stage for treatment. This can include examination under anaesthesia, scopes and scans.

    The stages of cervical cancer are:

    • Stage I

      The cancer is still small and has yet to spread to the lymph nodes or other parts of the body.
    • Stage II

      The cancer has grown larger and may have spread beyond the uterus and cervix, or to the lymph nodes.
    • Stage III

      The cancer has spread to the lower part of the vagina or the pelvis. It may have grown large enough to block the ureters (the tubes that carry urine from the kidneys to the bladder).
    • Stage IV

      The cancer may have spread further, beyond the pelvis and to organs such as the lungs, bone or liver.
  • Treatment depends on the stage of cervical cancer.

    • Localised procedures

      At its pre-cancer stage, the doctor will use local ablative or excision procedures to remove the abnormal cells before they become cancerous. These procedures include conisation, cryosurgery, or cauterisation, which have minimal impact on the surrounding healthy tissues.
    • Surgery

      Treatment for cervical cancer via surgery is only possible if the disease is still confined to the cervix (less than Stage 2). The treatment usually involves removing the uterus, cervix and the surrounding tissue, a procedure known as radical hysterectomy. This has implications on the patient’s fertility, and the surrounding tissue removal makes the hysterectomy more complex compared to the hysterectomy done for other common conditions such as fibroids.
    • Radiotherapy

      Radiotherapy uses high-energy x-rays to prevent the further growth of the cancer. It may be done externally, with a machine that targets the radiation directly at the tumour, or it may be done internally using a small capsule containing radioactive material that is inserted into the cervix.
    • Chemotherapy

      Chemotherapy uses powerful medications to kill cancer cells. It may be recommended for more advanced cancer or if the cancer has spread to other parts of the body.

      Chemotherapy and radiotherapy are the main form of treatments used for more advanced stages of cervical cancer, rather than surgery.
    • Immunotherapy

      Also known as biological therapy, this form of treatment uses your own immune system to target cancer cells and prevent their growth. It may be recommended if chemotherapy is not effective.

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  • Complications can arise in advanced cervical cancer or as a result of surgery.

    Complications of advanced cervical cancer include:

    • Pain

      Pain is a common symptom if the cancer has spread into nerve endings, bones or muscles. Pain relievers, either over-the-counter or prescription, may help.
    • Kidney failure

      In some cases, the tumour may lead to a build-up of fluid in the kidneys (hydronephrosis) which can lead to loss of kidney functions (kidney failure). It may be treated using a stent to widen the ureters or inserting a tube that allows urine to drain.
    • Blood clots

      Tumours, especially large ones, may press on veins in the pelvic area, slowing the flow of blood to the legs. This can form a blood clot that causes pain, swelling or tenderness, warmth or redness in the legs. It can cause further complications or death if a clot travels to the lungs and blocks the flow of blood (pulmonary embolism). Blood clots may be treated with blood-thinning medications, compression clothing, or a combination of both.
    • Bleeding

      Bleeding can occur if the cancer spreads into the vagina, bowel, bladder or rectum. It may be treated with medication or severe bleeding may require surgery or radiotherapy.
    • Fistula

      A fistula is a rare complication of advanced cervical cancer. A fistula is a channel that develops between the bladder and vagina, leading to persistent discharge of fluid from the vagina. It may be repaired with surgery or if this is not advisable, medication can help to reduce the discharge.

    Complications of cervical cancer surgery include:

    • Early menopause

      Surgical removal of the ovaries or damage resulting from radiotherapy may trigger early menopause. This means your monthly periods will become irregular or cease and you may experience hot flushes, vaginal dryness, mood changes and other symptoms.
    • Narrowing of the vagina

      Radiotherapy may cause the vagina to narrow, which make sexual intercourse painful or difficult. Hormone cream or vaginal dilators may help.
    • Lymphoedema

      Removal of the lymph nodes in the pelvis may affect the lymphatic system’s ability to drain excess fluid. This can lead to a build-up of fluid in the tissues, known as lymphoedema, which can cause swelling. In cervical cancer, this usually affects the legs. Specially-designed bandages or compression clothing may help.
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