* At the end of the post, you’ll find a video interview with Assist. Prof. Dr. Andrej Cokan, MD, specialist in gynecology and obstetrics.

Although cervical cancer is the most preventable cancer among all cancers, it is still the fourth most common cancer in women worldwide and one of the most common cancers in younger women. It is certainly important to highlight that, due to its effective screening program ZORA, Slovenia ranks among European countries with the lowest burden of cervical cancer.

ZORA is a national preventive program for detecting precancerous and early cancerous changes in the cervix. This means that within the ZORA program, gynecologists screen healthy women between 20 and 64 years of age (i.e., through screening, ZORA is a screening program) to timely detect those who have a precancerous stage or an early stage of cervical cancer (CC).

HPV – Human Papillomavirus; it is a virus from the Papillomaviridae family that causes papillomas in humans and is sexually transmitted. It is transmitted through vaginal, oral, and anal sexual intercourse, as well as through close skin or mucous membrane contact. It can also be transmitted from mother to newborn during childbirth. Approximately 200 strains are known (divided by different numbers), among which high-risk strains, important for the development of genital carcinomas, number about 45 (e.g., HPV-16, HPV-18..), and low-risk strains, which cause shorter infections that usually resolve on their own and cause warts or silent inflammations (HPV-6, HPV-11..). HPV infection is not only associated with the development of CC; partners without any symptoms are also carriers, and because it is transmitted through all forms of sexual intercourse and close contact, HPV can also cause cancer of the penis, anus, throat, vagina… Most of us encounter at least one strain in our lifetime. And because there are often no symptoms and we don’t know we are infected, the virus spreads among the population without them knowing. And since men are also carriers, a woman can be cured, but if her partner is infected, the problems can recur in the woman. Therefore, HPV IS NOT ONLY A WOMEN’S ISSUE! It’s just that for men, we don’t have preventive programs for early detection of precancerous and cancerous changes, except for vaccination.

PAP – is the abbreviated name for the Papanicolaou test, named after the Greek-American physician and scientist Georgios Nikolaou Papanikolaou. He is best known for developing the Pap smear, a screening test for cervical cancer. He was a pioneer in the field of cytopathology, the study of diseases at the cellular level, and his work continues to significantly impact women’s health today. The PAP test is just one of the tests used to detect precancerous and cancerous changes in the cervix.

LLETZ – is one of the excisional procedures, involving excision or removal with an electrical loop. Another such procedure is, for example, scalpel conization. In both procedures, diseased tissue is removed using a different method or “instrument.” Both procedures are also very important from a diagnostic perspective, as they allow for histopathological examination of the removed tissue in the laboratory, where the pathologist determines the stage of the precancerous change.

Preventive examinations

The PAP smear is the basic examination for successful and widespread detection of precancerous cervical changes and non-invasive cervical cancer, performed every 3 years as part of the national preventive screening program ZORA. Assist. Prof. Dr. Andrej Cokan, MD, specialist in gynecology and obstetrics, explains in the interview below why more frequent smears are not sensible if previous smears are negative.

The cervix is covered with epithelium, i.e., covering tissue – mucous membranes of different types. One comes from the uterus to the cervix and one from the vagina to the cervix. At the point where these two different covering tissues intertwine, irregularities in maturation can occur, leading to cellular differences, all the way to the formation of atypical (neoplastic) cell forms. And the smear must be taken at that specific spot. In Slovenia, this is done by a gynecologist, but abroad, it is also performed by midwives or specially trained nurses.

The smear is performed every three years from the age of 20 up to 64, for sexually active women (even if you’ve only had one sexual encounter in your life, and even if you’ve always used a condom until now).

Sometimes, after a smear, your gynecologist may inform you that the smear is “slightly” altered. It’s important to state that not every smear that isn’t perfectly normal indicates precancerous or cancerous changes; it could also be due to inflammation, including hidden inflammations that we otherwise wouldn’t detect. Therefore, smears are classified into NEGATIVE RESULTS, when there are non-neoplastic changes in the smear, such as inflammation, regeneration, consequences of mechanical effects from an IUD, some therapy, consequences of abnormal epithelial keratinization, and PATHOLOGICAL RESULTS. However, even within pathological results, we again have a broad group of these. And further action depends on the type of cellular changes in the smear. Therefore, trusting your gynecologist, who will adjust examinations, smears, and further procedures, is crucial! Even a negative result does not guarantee 100% absence of HPV, as it could be a silent infection or a small amount. Well, we might also get a result that everything is fine, but we could have HPV in us, just a small amount. And as we mentioned before, we have different HPV genotypes, and not all of them cause CC; it could be silent infections or condylomas (warts).

More about pathological smears here.

The pre-invasive phase of the disease can last for several years and is asymptomatic. That’s why it’s even more important to attend preventive smears. In case of atypical changes, your gynecologist will also be more attentive.

Symptoms indicating advanced disease may include: contact bleeding during sexual intercourse, bloody and foul-smelling discharge, and later also intermenstrual bleeding.

Based on the smear, a special classification is used to determine how widespread the cancer is. Various diagnostic procedures assist in this: clinical examination, histopathological analysis, and imaging diagnostics. Professional guidelines and recommendations are clearly defined and are also freely available here.

More about treatment in the video below.

List of gynecologists in the National ZORA program with their contact information.

HPV Testing

Testing for HPV for both men and women can be done at the Institute of Microbiology and Immunology in Ljubljana.

You can prevent HPV infection in several ways:

Vaccination: HPV vaccines are available for men and women. Vaccination is recommended for all children at 11 or 12 years of age (in the sixth grade and is free for both girls and boys) and can be administered up to 45 years of age.

Healthy lifestyle: balanced diet, avoiding harmful environmental influences, avoiding harmful habits (smoking!!!), avoiding stress – all these are mentioned not only for cancer prevention but also for other conditions, e.g., cardiovascular diseases. Self-care.

Safe and responsible sexuality: Condom use can reduce the risk of HPV infection but does not provide complete protection, as HPV can infect areas not covered by a condom.

Limit the number of sexual partners: More sexual partners can increase the risk of HPV infection.

Avoid sexual contact with individuals who have HPV symptoms: HPV can be transmitted even if there are no visible symptoms.

Regular (preventive) examinations: Cervical cancer screening is recommended for women from the age of 20 onwards. Screening examinations can detect abnormal cell changes caused by HPV, allowing for early treatment and prevention of cervical cancer.

It is advised that girls choose their gynecologist at age 15 and also have a conversation with them about safe and responsible sexuality.

Vaccination

For women, the risk of infection decreases with age, while for men, it does not, as they have a weaker immune response to the infection. However, unlike women, the advantage for men is that they produce more antibodies, so it is important to vaccinate boys as well. Since 2007, a vaccine has been available in Slovenia that successfully prevents infections with certain HPV genotypes. Since 2009, vaccination has been free for all girls in the 6th grade of primary school, and since 2021, also for boys in the 6th grade. Why then? Because the immune response is better. Despite vaccination, regular gynecological examinations with smear collection are necessary for women, as the vaccine does not protect against all HPV viruses. In addition to regular smears, the aforementioned methods of preventing infection are also important.

HPV vaccination can successfully prevent:

• around 50−80% of high-grade precancerous cervical changes (HSIL – CIN 2 and CIN 3);
• around 70−90% of cervical cancer;
• a proportion of other HPV-related precancerous and cancerous changes of the vagina, external genitalia, and cancers of the oral cavity and pharynx in both sexes;
• around 90% of genital warts (4- and 9-valent vaccine) in both sexes.

Since the vaccine is not therapeutic (it does not cure existing infections), vaccination is most effective if performed before the first sexual intercourse.

Three HPV vaccines are available:

• 2-valent for protection against infection with high-risk HPV genotypes 16 and 18;
• 4-valent for protection against infection with HPV 16 and 18, and low-risk HPV genotypes 6 and 11;
• 9-valent for protection against infection with seven high-risk HPV genotypes 16, 18, 31, 33, 45, 52, 58 and two low-risk HPV 6 and 11 (Feb, 2023).

Check if you can get vaccinated at your gynecologist; otherwise, you can get vaccinated at the NIJZ (National Institute of Public Health).

Messages from experts at the HPV vaccination roundtable (Sept 3, 2021)

More information about HPV, CC, the national screening program ZORA…

Pregnancy

Pregnancy is a special condition in all areas. This also applies to cervical smears. In the interview, Assist. Prof. Dr. Cokan, MD, specialist in gynecology and obstetrics, answers questions such as: are smears done during pregnancy, what about pregnancy and childbirth if you’ve had previous cervical procedures…

Approximately 3% of all CC cases are diagnosed during pregnancy. Treatment here is again additionally specific and depends not only on the stage but also on the duration of pregnancy, and how to handle pathological smears during pregnancy. Professional recommendations and guidelines are clearly defined for the pregnancy period and are available here.

The most frequent questions and answers regarding smears, HPV, ZORA, CC can also be found at this link.

If you didn’t find the answer to your question in the video, you can ask it under the video on Instagram. For specific health advice, contact your chosen gynecologist, who will refer you appropriately if needed, or you can find information here at https://gineko-cokan.si/.