christiana p. Calagui-damaso, m.d.

,
fpsms
ob-gyn
Malignant Diseases of the Cervix :
Microinvasive and Invasive Carcinoma:
Diagnosis and Management

Anatomy and Physiology of the

Cervix

The anatomy of the uterine cervix

narrow inferior segment of the uterus which
projects into the vaginal vault.
It is a fibromuscular organ lined by mucous
membrane and measures 3 cm in length and
2.5cm in diameter
adult - angled downwards and backwards.

shape of the external os

nulliparous cervix: small round
os

multiparous cervix : fishmouth,

slitlike

The cervix after menopause :

narrow os

Main Anatomical Regions of the Cervix

1. Endocervix
extends from the isthmus (internal os) to the
ectocervix and contains the endocervical canal
It is lined by mucous secreting columnar
epithelium which is thrown into folds and projects
into the underlying stroma forming complex
glands or crypts

 luminal surface of the

endocervical canal and
crypts is lined with a
single layer of columnar
cells
lining is made up of tall
cylindrical cells
arranged in a picket
formation

2. Ectocervix
extends from the squamo columnar junction to
the vaginal fornices
covered by non keratinising stratified squamous
epithelium

3. Squamocolumnar
Junction (SCJ)
located at the point
where the columnar
epithelium and the
squamous epithelium
meet

4. Transformation zone (TZ)

incorporates the area of metaplastic change in the
cervix
cells of the transformation zone are
extremely susceptible to carcinogens and most
cancers arise in the TZ

Before puberty - located at the external

os

Adolescence produces eversion of

endocervical epithelium and exposure
to the vaginal environment

after the menopause - usually

within the endocervical canal

squamous epithelium of the

0.5 mm thick
ectocervix
provides a protective covering for the portio
vaginalis of the cervix
fully mature under the influence of estrogen but
only semi- mature under the influence of
progesterone

 The mature squamous

epithelium consisted of 1020 layers of epithelial cells
which can be divided into
three zones

 basal zone
single layer of cylindrical cells 12 m diameter
main function is epithelial regeneration

mid or parabasal zone

composed of maturing squamous cells which have
more abundant cytoplasm than those of the of
the basal zone and hence appear slightly large
than the cells of the basal zone

 superficial layer
composed of several layers of loosely attached
cells that are broader and thinner than those of
the mid zone
They have small nuclei 2-3 m diameter

 Epithelium at birth and prior to the menarche:

At birth, the cervical epithelium shows some
maturation reflecting the actions of maternal
hormones in utero
Within a few days the effect wears off and the
cervical epithelium becomes thin and immature and is
comprised of only a few layers of parabasal type cells
It remains in this state until the menarche

 Proliferative phase of the menstrual cycle

The epithelium responds to the influence of
estrogen by complete maturation

Squamous epithelium: estrogen

response

18 - 20 layers of large
squamous cells containing
keratin precursors which
protects the cervix from the
vaginal environment to
which it is exposed
cells in the surface layers
are 50m diameter and
have abundant cytoplasm
and nuclei 2m diameter

 Secretory phase of the menstrual cycle and

pregnancy
Under the influence of progesterone (or oral
contraceptives / hormone replacement therapy)

 the epithelium is semimature and is 10-18 layers

thick

The surface cells have small

open vesicular nuclei about
5 m diameter and may
contain glycogen granules

In pregnancy the epithelial

cells contain
abundant glycogen

 After the menopause

cervix reduces in volume and the squamous
epithelium becomes atrophic

 It is thinner and
stratification and
glycogenation is lost
infection is common Because the epithelium is
so thin

Metaplastic change in the cervix and its physiological

basis

process of metaplasia
- It starts initially in the crypts and at the tips of the
endocervical villae which gradually fuse

Eventually the whole of the everted endocervical

epithelium may be replaced by squamous epithelium.

From birth until puberty

the endocervical epithelium is composed of columnar
epithelium
ectocervix - native squamous epithelium

 During puberty and first pregnancy the cervix

increases in volume in response to hormonal
changes

The endocervical epithelium everts onto the

ectocervix (portio vaginalis) exposing it to the
acid pH of the vagina
This provides a stimulus for metaplastic change of
the columnar epithelium

Epidemiology and Risk Factors

Invasive cancer of the cervix is considered a
preventable disease because it has a long
preinvasive state, cervical cytology screening
programs are currently available, and the
treatment of preinvasive lesions is effective

Incidence
cervical cancer - second most common and
the fifth most deadly cancer in women

affects about 16 per 100,000 women per year

and kills about 9 per 100,000 per year
approximately 80% of cervical cancers occur in
developing countries

 Philippine Cancer Facts and Estimates

Incidence of cervical CA remained stable from 1980-2005
Annual age-standardized incidence rate of 22.5 cases per
100,000 women
2005 7,277 new cases of cervical CA, with 3807 reported
deaths

Overall 5-year survival rate 44%

Mortality rate 1/10,000 women

2/3 of cervical CA in the Philippines are

diagnosed in an advance stage, and mortality
is high
advance clinical stage at presentation
Significant proportion of patients do not receive
or complete prescribed courses of treatment

Risk Factors
HPV Infection HPV 16 and 18
The presence of HPV-DNA in cervical neoplasia is
the first necessary cause of a human CA identified
High Grade ( invasive cancer)
HPV type 16, 18, 45, 56

Intermediate Grade (CIN II / III)

HPV type 31, 33, 35, 51, 52

Low Grade (Condyloma a. / CIN I)

HPV type 6, 11, 40, 41, 42

Parity of 7 4x increase
High parity may increase the risk of cervical CA
because it maintains the transformation zone on
the ectocervix for many years facilitating the
direct exposure to HPV
Hormonal changes induced by pregnancy may also
modulate the immune response

Longterm use of OCP 4x increase with HPV

Infection
Increased significantly with a use of 5-9 years and with
a use of 10 years
Hormone related mechanisms may influence the
progression from premalignant to malignant cervical
lesions by promoting integration of HPV DNA into the
host genome, which results in the deregulation of E6
and E7 expression
Associated with Adenocarcinoma

Smoking the risk of SCCA increases in current

smokers with the number of cigarettes smoked
per day and with younger age at starting smoking
Nicotine and tobacco-specific carcinogens have been
detected in the cervical mucus of smokers
Chemical tobacco-related carcinogens may exert a
direct mitogenic effect causing DNA damage
No association between smoking and adenocarcinoma

 C0- infection with HPV and C. trachomatis or HSC-2

Women with HIV (+) infection

Increased lifetime number of sexual partners

Risk of invasive cell CA increased

Early age at first intercourse - 14 y/o

Early age at first full term pregnancy ( 17 y/0)
Risk of both invasive and CIN 3/CIS

Male circumcision reduced risk of penile

HPV infection

Risk of developing invasive cervical CA is 3-10x

greater in women who have not been
screened
Low socio economic status

HISTOLOGIC TYPES

CERVICAL CARCINOMA
Gross lesions may
be
Fungating or
exophytic
Ulcerating
Infiltrative or
endophytic

Types

Modified WHO Histological Classification

A) Epithelial tumors
1) SCCA
2) Adenocarcinoma
3) Others

Adenosquamous
Glassy cell/clear cell
Small cell
Mucoepidermoid
Adenoid cystic
Carcinoid like
Undiferentiated

SQUAMOUS CELL- 80-85 %

Microinvasive squamous cell carcinoma

one or more tongues of carcinoma extend down from the

dysplastic epithelium and break through the basement
membrane to invade the underlying stroma

Squamous cell carcinoma, non keratinizing

Nests of neoplastic squamous cells have invaded through a
chronically inflamed stroma

SCCA, LARGE CELL NON KERATINIZING

Discrete islands of uniform, large cells with abundane cytoplasm separated by stroma

- LARGE POLYHEDRAL CELLS

- ATYPICAL NUCLEI
- ACIDOPHILIC CYTOPLASM
- NEGATIVE FOR KERATIN PEARL
AND KERATOHYALIN

Squamous cell carcinoma, keratinizing

irregular nests of squamous cells forming pearls are separated by fibous
stroma. The nests has pointed projections

NEOPLASTIC SQUAMOUS CELLS

KERATIN PEARL

VERRUCOUS CARCINOMA

- WARTY TUMORS APPEAR AS LARGE, BULBOUS MASSES

HIGHLY-DIFFERENTIATED SQUAMOUS CELL CARCINOMA
- VERRUCOUS PATTERN
- INVADES WITH A PUSHING BORDER IN THE FORM OF BULLOUS PEGS
OF NEOPLASTIC CELLS

ADENOCARCINOMA 15-20 %
Tall columnar glandular cells with basally oriented nuclei
and apical cytoplasmic mucin
Resembles endocervical mucinous glandular epithelium

Atypia, pleomorphism, mitoses, invasion

Not appear to be affected by the usual sexual factors
Typical variant often contains intracytoplasmic mucin and is
related to the mucinous cells of the endocervix
(endocervical pattern)

Group of malignant glandular neoplasm

ADENOCARCINOMA, ENDOCERVICAL TYPE

4X

10X

- TUMOR CELLS WITH CLEAR CYTOPLASM RESEMBLING

ENDOCERVICAL LINING EPITHELIUM
- MORE FREQUENTLY STAIN POSITIVE FOR CARCINOEMBRYONIC ANTIGEN

MUCINOUS CARCINOMA

10X

- NEOPLASTIC CELLS FORMING GLANDS FLOATING IN MUCIN

QUIT

ENDOMETRIOID ADENOCARCINOMA
(ADENOCARCINOMA WITH SQUAMOUS DIFFERENTIATION)

10X

- NEOPLASTIC GLANDS WITH ATYPICAL NUCLEI AND

SQUAMOUS METAPLASIA
QUT

CLEAR CELL ADENOCARCINOMA

- NEOPLASTIC CELLS FORMING

GLANDS
- ATYPICAL NUCLEI
- CLEAR CYTOPLASM

- HOBNAILED / ECCENTRIC NUCLEI

SEROUS ADENOCARCINOMA

- PLEOMORPHIC NEOPLASTIC CELLS FORMING PAPILLARY STRUCTURES

- FIBROUS STROMA

ADENOSQUAMOUS
Mixture of squamous and
glandular components
Squamous component is
malignant (squamous cell
carcinoma)
consisting of large cells containing
cytoplasm with a ground-glass
appearance.
Glassy cell carcinomas tend to
metastasize early to lymph nodes
as well as to distant sites and
usually have a fatal outcome

CLEAR CELL
Similar to clear cell
carcinoma of the ovary
Vagina or cervix may be
involved
Adenocarcinoma variant
with clear cytoplasms and
hobnailing of the nuclei
Related to maternal DES
exposure

SMALL CELL
< 5%
Cells are small hyperchromatic
with scant cytoplasm
cells are small anaplastic cells
with scan cytoplasm
they behave very aggressively
and frequently associated with
widespread metastasis to
multiple sites, including bone,
liver, skin, and brain

ADENOID CYSTIC CARCINOMA

4X

20X

- SMALL PLEOMORPHIC CELLS WITH HYPERCHROMATIC NUCLEI

- INDISTINCT CYTOPLASM
-PSEUD0-GLANDS AND MICROCYSTS
-AGGRESSIVE AND MAY RESEMBLE CYLINDROMAS OF SALIVARY GLAND OR
BREAST ORIGIN AND HISTOLOGICALLY MAY RESEMBLE BASAL CELL CARCINOMAS OF THE SKIN (ADENOID BASAL, OR BASALOID, CARCINOMAS).

ADENOID BASAL CELL CARCINOMA

- NEOPLASTIC BASAL CELLS FORMING

MICROCYSTS AND PSEUDOGLANDS
(NO TRUE BASEMENT MEMBRANE)
- PERIPHERAL PALISADING OF NUCLEI
- RETRACTION SPACES
- MELANIN PIGMENTS

 Adenoma malignum
consist of well-differentiated mucinous glands that
vary in size and shape and infiltrate the stroma
tend to be deeply invasive and metastasize early

 Non-small cell neuroendocrine tumors

contain intermediate to large cells, high-grade
nuclei, and eosinophilic cytoplasmic granules of
the type seen in neuroendocrine cells

MICROINVASIVE CARCINOMA OF
THE CERVIX
tiny lesions that have begun to invade the
cervical stroma

designated as stage IA

CARCINOMA OF THE CERVIX

Clinical Considerations

Signs and Symptoms

early stages of cervical cancer may be completely

assymptomatic
Vaginal bleeding
moderate pain during sexual intercourse

vaginal discharge
vaginal mass

 Symptoms of advanced cervical cancer

loss of appetite
weight loss
Fatigue
pelvic pain
back pain
leg pain
swollen legs
heavy bleeding from the vagina
bone fractures,
and/or (rarely) leakage of urine or feces from the vagina

diagnosis is established by biopsy of the tumor

Staging - depends primarily on the pelvic
examination
designation may be modified by general physical
examination, by chest radiographic examination,
by intravenous pyelography (IVP), or computed
tomography (CT) and is not changed based on
operative findings

FIGO Staging
Stage I the CA is strictly confined to the
cervix
IA invasive CA that can be diagnosed only
microscopically with deepest invasion of 5mm
and largest extension of 7 mm
IA1 measured stromal invaion of 3 mm depth
and extension of 7 mm
1A2 - measured stromal invaion of 3 mm depth
and extension of 7 mm

 Stage IB-clinically visible lesion limited to the

cervix uteri or subclinical cancers greater tahn
stage 1A
1B1 clinically visible lesions 4 cm
1B2 - clinically visible lesions 4 cm

 Stage II the carcinoma extends beyond the

uterus but has not extended to the pelvic wall
or to the lower third of the vagina
IIA without parametrial invasion
IIA1 - clinically visible lesions 4 cm
IIB2 - clinically visible lesions 4 cm

IIB with obvious parametrial invasion

 Stage III the carcinoma involves the lower

third of the vagina and or causes
hydronephrosis or non functioning kidney
IIIA tumor involves the lower third of the vagina,
with no extension to the pelvic wall
IIIB extension to the pelvic wall and/or
hydronephrosis or non functioning kidney

 Stage IV the carcinoma has extended

beyond the true pelvis or has clinically
involved the mucosa of the bladder or rectum.
A bullous edema does not permit a case
allotted to be stage IV
IVA spread of growth to the adjacent organs
IVB spread to distant organs

Natural History and Spread

Exophytic growth pattern cauliflower like
appearance extruding from the cervix usually
producing abnormal bleeding or staining

Endophytic assymptomatic
- early stage of development
- tend to be deeply invasive when diagnosed
- usually starts in the endocervical location
and often fill the cervix and lower uterine
segment, resulting in a barrel shaped cervix

- tend to metastasize to regional pelvic nodes,

and because of the late diagnosis, they are
often more advance than the exophytic
variety

Initially, cervical carcinoma spreads to the

primary pelvic nodes
which include the pericervical node, presacralthe
hypogastric (internal iliac) and external iliac nodes,
and the nodes in the obturator fossa near the
vessels and nerve

tumor spread proceeds secondarily to the

common iliac and paraaortic nodes

Prognostic Factors
FIGO stage
most important determinant of prognosis for
carcinoma of the cervix

tumor characteristics
tumor size

patient characteristics

Patients with adenocarcinomas of the cervix

have a poorer prognosis than patients with
squamous cell carcinomas of the cervix

MANAGEMENT
Pretherapy Evaluation
conducted to determine the extent of disease,
to arrive at an accurate clinical staging, and to
plan the program of therapy
thorough history and physical examination,
routine blood studies, an intravenous pyelogram
or a CT scan, and chest radiograph

Operative Therapy: Radical Hysterectomy,

Pelvic Node Dissection
Class I

extrafascial hysterectomy

removal of the entire cervix and uterus.

ureter is not disturbed from its bed.
used after preoperative radiation for treatment of
a barrel-shaped cervix

class II operation
modified radical hysterectomy
removes more paracervical tissue than class I, but
the ureters are retracted laterally yet are not
dissected from their attachments distal to the
uterine artery, and the uterosacral ligaments are
ligated approximately halfway between the uterus
and rectum.
The operation is usually performed with pelvic
lymphadenectomy

treat small microscopic carcinomas of the cervix

for tumors smaller than 2 cm (median 1.1 cm)
with 5-year survival of 96%

class III operation

radical hysterectomy (Meigs-Wertheim
hysterectomy
uterine artery is ligated at its origin from the
anterior division of the hypogastric artery, and the
uterosacrals are ligated deep in the pelvis near the
rectum

Class IV
complete dissection of the ureter from its bed and
sacrifice of the superior vesical artery

class V operation
involves resection of the distal ureter or bladder
or both with reimplantation of the ureter into the
bladder (ureteroneocystotomy)

Management
Concurrent chemotherapy and complete
radiotherapy standard treatment
For patients who are unable to receive
chemotherapy, radiation treatment alone may
be given
Adenocarcinoma have shown no significant
difference in clinical behavior from SCCA

 Stage 1A1
a) Good surgical risk
Desirous of pregnancy, no LVSI
Negative margins, observe
Positive margins repeat cone biopsy

Not desirous of pregnancy

EHBSO
Modified RHBSO with LND if with LVSI

 B) Poor surgical risk

Negative margins, observe
Positive margins repeat cone biopsy, brachytherapy
Positive LVSI pelvic EBRT + brachytherapy

 Stage 1A2
a) Good surgical risk
Desirous of pregnancy, no LVSI

Radical trachelectomy and extraperitoneal or

laparoscopic pelvic lymphadenectomy

Not desirous of pregnancy

Modified RHBSO, LND

 B) Poor surgical risk

Pelvic EBRT + brachytherapy

 Stage IB1, II A
a) Good surgical risk

RHBSO, LND
Concurrent chemotherapy, pelvic EBRT ,
brachytherapy
Radical vaginal hysterectomy +/- BSO and
extraperitoneal or laparoscopic pelvic
lymphadenectomy
Radical trachelectomy and extraperitoneal or
laparoscopic pelvic lymphadenectomy

 B) poor surgical risk

concurrent chemotherapy, pelvic EBRT,
brachytherapy

 Stage IB2, IIA

Concurrent chemo, pelvic EBRT, brachytherapy
Neoadjuvant chemo (3 rapidly delivered courses
of platinum based chemo), followed by RHBSO,
BLND plus adjuvant post op radiation or cherad
Chemotherapeutic options
Cis/Pacli
PVB (Cis/Vinblastine/Bleomycin)
Cis/Ifosfamide

 Pelvic EBRT concurrent with chemo followed

by RHBSO with selective lymphadenectomy
Primary radical hysterectomy and bilateral
pelvic lymphadenectomy, followed by
chemorad

 Stage IIB IV
Concurrent chemo, pelvic EBRT + brachytherapy,
chemorad
Paraaortic lymphadenectomy + brachytherapy +
concurrent Cisplatin chemo
If with evidence of distant metastasis on imaging
or biopsy: systemic combination chemotherapy
and individualized RT

Fertility-Sparing Surgery for Patients with

Cervical Cancer
Radical trachelectomy, either vaginal or
abdominal, can be performed with adequate
safety and with acceptable pregnancy rates

Laparoscopic Surgery for Cervical Cancer

tumor itself can be removed through the
vagina, avoiding the need for an abdominal
incision to remove the tumor
pelvic and paraortic lymph nodes can be
removed through laparoscopic ports

laparoscopy
associated with a reduction of surgical adhesions

associated with less postoperative pain and

shorter length of hospital stay

Sentinel Lymph Nodes

identifies the first site of nodal metastases in a
regional lymph node basin

Complications
small bowel obstruction
Fistulas from the urinary tract, particularly
ureterovaginal fistulas
postoperative bladder dysfunction

Outcomes after Surgical Treatment

80% to 90%
5-year survival rates for women with stage IB
cervical cancer treated with radical hysterectomy
and pelvic lymphadenectomy

Radiation Treatment
External beam radiation
admin-istered in fractions, usually 180 cGy/day 5
days per week to destroy the tumor without
causing permanent damage to normal tissues

Outcomes
Radical radiation therapy achieves excellent
survival and pelvic disease control rates in
patients with stage IBIIA cervical cancer

CHEMORADIATION
use of chemotherapy to sensitize cells to
radiation therapy has been shown to improve
local regional control
Advisable to patients with these high-risk
factors after radical hysterectomy for stage
Ia2, Ib, and IIa disease

Studies
cisplatin-based concurrent chemoradiation was a
superior treatment when compared with
hydroxyurea and concurrent radiation
chemoradiation is the treatment of choice for
stage IIb to IVa disease and that those patients
with stage Ib2 and IIa disease may also benefit
from chemoradiation

Paraaortic Nodes
Patients with paraaortic lymph node
involvement can be treated effectively with
extended-field radiation
Patients are treated with a combination of
external beam radiation therapy and
brachytherapy

Radiation Complications
related to dose, volume treated, and
sensitivity of the various tissues receiving
radiation
diarrhea and nausea
Scarring of normal tissues can lead to severe
radiation fibrosis

Vaginal or cervical ulcerations

Postradiation cystitis

hemorrhagic cystitis
Periureteral fibrosis
Proctosigmoiditis

Cervical Stump Tumors

Seen in patients who underwent supracervical
hysterectomy for nonmalignant disease
For patients with small stage IB tumors
operative approach similar to radical hysterectomy

Carcinoma of the Cervix Inadvertently

Removed at Simple Hysterectomy
Classification
(1) microinvasive cancer

(2) tumor confined to the cervix with negative

surgical margins
(3) positive surgical margins but no gross
residual tumor

(4) gross residual tumor by clinical examination

documented by biopsy
(5) patients referred for treatment more than 6
months after hysterectomy (usually for recurrent
disease)

treatment plan is based on the amount of

residual disease

surgeon can subsequently perform a radical

operation, removing the tissues that would
normally be removed at radical hysterectomy,
including the regional pelvic nodes

Carcinoma of the Cervix in Pregnancy

CA of the Cervix in Pregnancy

Rare
incidence of each stage at diagnosis
83% Stage I, 10% Stage II, 3% Stage III, 2% Stage
IV

Increased vascularity (produces a

cyanotic, bluish hue) stromal
edema, and stromal
hypertrophy, cause marked
enlargement of the cervix

Pregnancy triggers very active squamous

metaplasia which shows an exaggerated
acetowhite change in response to acetic
acid.
Increased vascularity and stromal edema
can cause a decrease in acetowhitening
but an exaggeration of vascular ity

Decidual changes can be confusing, and may even have features

consistent with invasive cancer, such as yellow coloration, and
atypical appearing vessels

 If the cytologic and hisytologic findings of

colposcopically directed biopsies are
comparable and suggest intraepithelial
neoplasia or CIS
Patient is observed and delivered
Final evaluation and therapy completed 6 weeks
postpartum

POSTPARTUM EVALUATION
The likelihood of disease progression during
pregnancy is small

Regression is more likely; 12% to 70%.

Patients should be reevaluated at least six
weeks postpartum to allow healing

RECURRENCES
tumor recurrence
one third of patients
reappearance of tumor 6 months or more after
therapy.
Metastases can occur anywhere, but most are in
the pelvis (centrally in the vagina or cervix or
laterally near the pelvic walls) or less frequently
distally in the periaortic nodes, lung, liver, or
bone.

Symptoms
Vaginal discharge
abnormal bleeding
Malaise
loss of appetite
leg swelling
Low back pain

Examineation
every 3 months the first 2 years

every 6 months from years 3 to 5

yearly thereafter

vaginal and cervical cytology (Pap smear)

complete physical and pelvic examinations

chest radiographs annually

IVP or abdominal pelvic CT -performed annually,
particularly during the first 2 years after
treatment when the majority of recurrences will
develop

Pelvic Recurrences
vaginal ultrasound
For patients who were initially treated by
surgery, radiation is usually prescribed for
pelvic recurrences

Pelvic Exenteration
central pelvic tumor recurrence

Anterior pelvic exenteration

removal of the bladder, uterus, cervix, and part
or all of the vagina

Posterior pelvic exenteration

removal of the anus and rectum and resection of the
uterus, cervix, and all or part of the vagina

Total exenteration
combined anteroposterior exenteration to
remove all the pelvic contents

Nonpelvic Recurrences
treated with radiation, surgery, or
chemotherapy

Chemotherapy
Patients with advanced, recurrent, or persistent
cervical cancer

Sarcomas
Very rare
multiagent chemotherapy followed by
operation
better prognosis

Vaccination
Gardasil and Cervarix
Both vaccines can prevent most cases of cervical
cancer if given before a girl or woman is exposed
to the virus
both can prevent most vaginal and vulvar cancer
in women
Gardasil can prevent genital warts in women and
men

recommended for girls and boys ages 11 to 12

although it may be given as early as age 9

It is important for boys and girls to receive the

vaccine before they have sexual contact and are
exposed to HPV
Once infected with HPV, the vaccine may not be
as effective.

If not fully vaccinated at ages 11 to 12, the

Centers for Disease Control and Prevention
(CDC) recommends that girls and women
through age 26 and boys and men through
age 21 receive the vaccine

men may receive the HPV vaccine through

age 26 if desired

 Both vaccines are given as a series of three

injections over a six-month period

second dose is given one to two months

after the first dose
third dose is given six months after the first
dose.

Prevention
Total sexual abstinence prevents HPV infection
Lifetime mutual monogamy prevents HPV infection
Consistent and correct use of barrier protection decreases cervical
CA incidence
Vaccination against HPV 16/18 is efficaceous against persistent HPV
infection and CIN 2

Oral supplementation with folic acid, B-carotene or vit c does not

enhance regression to premalignant cervical lesions

Thank you!!