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CERVICAL CANCER OVERVIEW — More than 11,000 people in the United States develop cancer of the cervix (cervical cancer) each year. Cervical cancer is a treatable condition, and there is a good chance of cure if it is found and treated in the early or precancerous stages.
Many people with cervical cancer are in their reproductive years, and it is common to have concerns about the impact of cancer treatment on future fertility (the ability to become pregnant). If you are in this situation, your health care provider can talk to you about your options. In addition to working with a gynecologic oncologist, you may be referred to a clinician with expertise in reproductive endocrinology and infertility.
This topic review has information for people with the earliest stages of localized cervical cancer who wish to preserve their fertility in the future. More information about cervical cancer screening and the standard treatment of all early-stage cervical cancers (which usually includes hysterectomy) is available separately. (See "Patient education: Cervical cancer screening (Beyond the Basics)" and "Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)".)
CERVICAL CANCER, FERTLITY, AND DECISION-MAKING — If you have been diagnosed with cervical cancer and had planned on trying to get pregnant in the future, it is normal to feel scared or overwhelmed. You might feel like you have to choose between doing what seems best for your own health and what might be best for preserving your fertility.
Every person's circumstances are different, and you will need to learn about your options and make the best decision for you based on your situation. Talking to an experienced health care provider you trust can help.
FERTILITY-SPARING TREATMENT OPTIONS FOR CERVICAL CANCER — "Early-stage" cervical cancer refers to stage IA1, IA2, IB1, and some small IIA1 tumors. Treatments that allow for preservation of fertility (meaning they will not interfere with your ability to get pregnant in the future) are typically only an option for people with stages IA1, IA2, or IB1 cervical cancer. Other factors (such as lymph node spread or size of the cancer) may also affect whether fertility-sparing treatment is an option. If fertility-sparing treatment is not an option for you, your health care provider can talk to you about other options for growing your family. (See 'Pregnancy options after radical hysterectomy or radiation' below.)
Options for treatment of early-stage cervical cancer include cone biopsy, trachelectomy, hysterectomy, and chemoradiation. If you have early-stage cervical cancer and there has been no spread to other organs or lymph nodes, you may be a candidate for less aggressive forms of treatment. Treatments that would allow you to carry a pregnancy in the future include the following (see "Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)", section on 'Cervical cancer treatment options'):
●Conization – Removal of a portion of the cervix.
●Simple trachelectomy – More extensive removal of the cervix.
●Radical trachelectomy – Removal of the cervix and surrounding tissues, but not the uterus.
In addition, the lymph nodes in the pelvis may be removed (a procedure called lymphadenectomy).
A procedure called sentinel lymph node biopsy is increasingly performed to reduce the extent of and complications associated with extensive lymph node dissection (removal). This procedure is not yet considered "standard of care"; however, it can be considered and performed by surgeons experienced with the technique. This approach is being evaluated in large studies.
Cervical conization — Cervical conization is the surgical removal of a cone-shaped portion of the cervix, including the cancerous area (figure 1). It is an option only for the earliest stages of cervical cancer (ie, stage IA1 and IA2 and very small IB1 lesions).
Conization is usually performed in the operating room after you receive anesthesia. Conization is performed through the vagina. Most people can go home the same day.
Simple trachelectomy — Some studies suggest that "radical" trachelectomy may not always be necessary for people with small lesions since the risk of the cancer spreading to the tissues next to the uterus and cervix (parametrium) is extremely low. The simple trachelectomy is similar to the radical trachelectomy in that it involves the complete removal of most of the cervix, but it does not include the removal of the parametrial tissue. It is, however, more extensive than a conization (figure 2).
Simple trachelectomy is an option for stage IA1, IA2, and small IB1 lesions measuring <2 cm. It is performed in the operating room, through the vagina, and is usually a day surgery like a conization. A cerclage (stitch) is not necessarily placed after the simple trachelectomy, but this depends on the amount of cervical tissue remaining after the procedure. The lymph nodes are removed through laparoscopy (in which special instruments are passed through a very small incision) prior to trachelectomy to make sure cancer cells have not spread to the lymph nodes.
Radical trachelectomy — Radical trachelectomy is defined as partial or complete surgical removal of the cervix and parametrium (the connective tissues next to the uterus and cervix). Radical trachelectomy removes much more of the cervix compared with cervical conization. It also involves the removal of lymph nodes in the pelvis.
The procedure is performed in the operating room after you receive anesthesia. Trachelectomy may be done through the vagina or through an incision on the abdomen, depending on the surgeon's preference. The procedure may also be performed using laparoscopy ("minimally invasive" surgery) or robotic surgery. The cervix and upper portion of the vagina may be completely or partially removed, depending on the size and depth of the cancer. A permanent "purse-string" suture (cerclage) is usually placed at the lower end of the uterus or remaining cervix (figure 2).
Before trachelectomy begins, the lymph nodes in the pelvis are removed to be sure that the cancer has not spread; this is called lymphadenectomy (figure 3). The nodes may be removed through an incision in the abdomen (if an abdominal incision is made for the trachelectomy); this allows the clinician to see the nodes directly. Alternatively, the nodes are removed with the assistance of a laparoscope if the trachelectomy is done vaginally, laparoscopically, or robotically.
After removal, the lymph nodes are examined under a microscope during the operation to preliminarily confirm that no cervical cancer cells are present. If any nodes are found to contain cancer cells, the trachelectomy is usually not performed, and more aggressive therapy (radical hysterectomy or chemoradiotherapy) is usually recommended. (See "Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)", section on 'Cervical cancer treatment options'.)
Follow-up — Following conization or trachelectomy, most gynecologic oncologists recommend avoiding sexual intercourse, not placing anything in your vagina, and avoiding baths or swimming for four to six weeks (showers are fine); these activities could potentially interfere with healing. It is normal to have some bleeding for approximately one week, although it should not be heavy. If bleeding becomes heavy (eg, soaks a pad in less than an hour) or continues for more than one week, tell your health care provider.
After conization or trachelectomy, it is important to have regular follow-up examinations and tests to ensure that there is no evidence of cervical cancer. A Pap test is done on cells taken from the residual cervix at each visit, and human papillomavirus (HPV) testing is recommended. HPV vaccination is also recommended to reduce the risk of HPV re-infection. (See "Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)", section on 'Monitoring' and "Patient education: Cervical cancer screening (Beyond the Basics)" and "Patient education: Human papillomavirus (HPV) vaccine (Beyond the Basics)".)
Need for further treatment — Further surgery may be required if abnormal or cancerous cells are found at the margins (edges) of the area that is removed during conization or trachelectomy. If you had conization, this could mean having a second conization, radical trachelectomy, or hysterectomy. If you had radical trachelectomy, this usually means a radical hysterectomy. (See "Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)".)
Additionally, chemoradiation may be necessary if, for example, cancer cells were found in your lymph nodes or if the tissue removed during trachelectomy suggests certain risk factors.
PREGNANCY AFTER CERVICAL CANCER TREATMENT — In most cases, doctors advise waiting 6 to 12 months after conization or trachelectomy before trying to get pregnant. This is to allow enough time to heal fully. Even then, there is a risk of pregnancy complications and/or infertility after cervical cancer treatment.
Infertility — There is an increased risk of infertility (difficulty becoming pregnant) if your cervix or lower uterus is scarred or narrowed from conization or trachelectomy. This could potentially prevent sperm from entering the uterus. If this happens, you may benefit from infertility treatment, such as intrauterine insemination (IUI); this can be done after dilating (widening) the cervical opening. With IUI, a small catheter is used to deliver sperm directly into the uterus.
If it is not possible to dilate (widen) the cervical opening or if IUI is unsuccessful, you might consider in vitro fertilization (IVF) with embryo transfer. It is important to make sure you know and understand all of your options; it often helps to speak with a reproductive endocrinologist who has expertise in this area. Knowing which options are available even before you undergo treatment for cervical cancer will help you feel empowered and prepared.
Cervical insufficiency — If you do get pregnant following conization or trachelectomy, you may have an increased risk of cervical insufficiency. This is when the cervix opens or thins earlier than normal during pregnancy. This can lead to miscarriage (pregnancy loss) or preterm delivery (when delivery occurs before 37 weeks of pregnancy).
Because of the risk of these issues, people who get pregnant after cervical cancer treatment are followed closely during their pregnancy. This generally involves regular checking of the length and opening (dilation) of the cervix. (See "Patient education: Preterm labor (Beyond the Basics)", section on 'Cervical length'.)
Pregnancy options after radical hysterectomy or radiation — It is not usually possible to become pregnant or carry a pregnancy after treatment with radical hysterectomy and/or chemoradiation therapy. However, advances in assisted reproductive technology may offer a way to have a biologically related child after this type of treatment.
Embryo cryopreservation (freezing) is a technique that has been available for many years. This approach requires delaying radical surgery, chemotherapy, or radiotherapy for several weeks and ensuring that sperm is available to fertilize an egg. Sperm can come from a partner or from a donor. You will need to take fertility medications and undergo a surgical procedure to harvest your eggs. An egg (oocyte) is combined with sperm to create an embryo, which is then frozen for use at a later time.
Another option is oocyte cryopreservation (freezing the egg before it is fertilized with sperm). Ovarian cryopreservation (freezing an ovary that has been surgically removed) is under investigation; further study is needed before this technique is available to the general public.
Since your uterus will have been removed or damaged by these cancer treatments, you will not be able to carry a pregnancy yourself. However, you may have the option of having a frozen embryo implanted into another person's uterus so they can carry the pregnancy for you; this is known as "gestational carrier pregnancy" or "surrogacy."
If you have any questions about your options, be sure to ask your health care provider or seek out a clinician with expertise in this area. Some people choose to grow their family in other ways, such as through adoption.
CLINICAL TRIALS — Progress in treating cervical cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials or read about clinical trials at:
●https://www.cancer.gov/about-cancer/treatment/clinical-trials
●https://www.clinicaltrials.gov/
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (https://www.cancer.net/research-and-advocacy/clinical-trials/welcome-pre-act).
WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Cervical cancer (The Basics)
Patient education: Cervical cancer screening tests (The Basics)
Patient education: Preserving fertility after cancer treatment in women (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)
Patient education: Follow-up of high-grade or glandular cell abnormal Pap tests (Beyond the Basics)
Patient education: Cervical cancer screening (Beyond the Basics)
Patient education: Cervical cancer treatment; early-stage cancer (Beyond the Basics)
Patient education: Genital warts in women (Beyond the Basics)
Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)
Patient education: Vaginal hysterectomy (Beyond the Basics)
Patient education: Preterm labor (Beyond the Basics)
Patient education: Miscarriage (Beyond the Basics)
Patient education: Sexual problems in females (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Cervical intraepithelial neoplasia: Terminology, incidence, pathogenesis, and prevention
Human papillomavirus infections: Epidemiology and disease associations
Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis
Management of early-stage cervical cancer
Management of locally advanced cervical cancer
Invasive cervical cancer: Staging and evaluation of lymph nodes
Management of recurrent or metastatic cervical cancer
HIV infection and malignancy: Epidemiology and pathogenesis
Preinvasive and invasive cervical neoplasia in patients with HIV infection
Radical hysterectomy
Human papillomavirus vaccination
Virology of human papillomavirus infections and the link to cancer
Gestational carrier pregnancy
Invasive cervical adenocarcinoma
Small cell neuroendocrine carcinoma of the cervix
The following organizations also provide reliable health information.
●American Society of Clinical Oncology
●Society of Gynecologic Oncology
●National Cancer Institute
1-800-4-CANCER
●American Cancer Society
1-800-ACS-2345
●The National Cervical Cancer Coalition
