Synopsis
Recognise symptomatic cervical cancer despite screening history, obtain colposcopic histology, stage local and nodal disease accurately and coordinate fertility-preserving surgery, radical chemoradiation, brachytherapy and recurrent-disease care.
- Persistent high-risk HPV causes most cervical cancer; HPV vaccination and screening prevent disease but a symptomatic cervix always enters a diagnostic, not screening, pathway.
- Key symptoms are postcoital, intermenstrual or postmenopausal bleeding, watery or offensive discharge, pelvic pain and dyspareunia; advanced disease causes leg oedema, renal obstruction and fistula.
- First-line assessment is speculum and bimanual examination followed by urgent colposcopy and directed biopsy of a suspicious cervix; do not rely on cytology alone to exclude invasion.
- The diagnostic reference standard is histology that defines squamous, adenocarcinoma or rarer type, depth and lymphovascular invasion where a cone specimen is used.
- MRI pelvis is preferred for local tumour, parametrial, vaginal and pelvic-organ staging; PET-CT or contrast CT evaluates pelvic, para-aortic and distant disease for radical planning.
- Very small stage IA1 squamous cancer without lymphovascular invasion may be treated by complete cone biopsy or simple hysterectomy, depending fertility and margin status.
- Fertility-preserving radical trachelectomy with nodal staging is limited to carefully selected small early tumours and requires obstetric and recurrence counselling.
- Early operable disease may undergo radical hysterectomy and nodal assessment; avoid combining radical surgery and full chemoradiation unnecessarily because morbidity accumulates.
- First-line curative treatment for locally advanced cervical cancer is external-beam radiotherapy with weekly cisplatin and mandatory image-guided brachytherapy, usually completed without avoidable prolongation.
- Brachytherapy is not an optional boost that external beam can routinely replace; overall treatment time and central dose are critical to local control.
- Recurrent or metastatic therapy uses platinum–taxane combinations with immune, anti-VEGF or other treatment according to PD-L1, prior cisplatin, anatomy, fistula risk and current funding.
- Relapse confined centrally after radiation may be considered for pelvic exenteration only after biopsy, complete staging and specialist resectability and rehabilitation review.
- Offer fertility preservation, ovarian transposition, menopause and sexual-health support before treatment when time and disease anatomy allow.
Key red flags
Persistent postcoital, intermenstrual or postmenopausal bleeding needs direct cervical examination even when the last screening test was negative.
A visible irregular, ulcerated or friable cervix requires urgent colposcopy and biopsy rather than a screening sample alone.
Heavy bleeding with syncope, tachycardia, hypotension or falling haemoglobin requires immediate haemostatic and transfusion support.
Flank pain, oliguria, rising creatinine or bilateral hydronephrosis suggests ureteric obstruction from parametrial or nodal disease.
Malodorous discharge, fever, pelvic pain and systemic illness can indicate infected tumour, pyometra or fistula with sepsis.
Leg oedema, sciatic pain, haematuria, rectal bleeding or pelvic sidewall fixation suggests advanced local or nodal involvement.
Brisk bleeding, shock, fever with necrotic discharge or obstructed infected uterus requires immediate resuscitation and specialist source control.
Investigation priorities
Identify a visible cervical lesion, bleeding source, vaginal extension, uterine and parametrial abnormality and infection.
Stage tumour size, stromal and parametrial invasion, vagina, bladder, rectum and pelvic nodes and plan surgery or brachytherapy.
Management branches
Postcoital, intermenstrual or postmenopausal bleeding or abnormal discharge persists.
- Take pregnancy, contraception, screening, infection and bleeding history and perform speculum and bimanual examination, stabilising major haemorrhage first.
- Refer a suspicious cervix directly for urgent colposcopy and biopsy rather than repeating screening cytology as the sole response.
- Once invasion is confirmed, obtain MRI and nodal or distant staging and refer to the specialist gynaecological oncology MDT with renal, fertility and anaesthetic assessment.