Introduction
Cervical cancer is the fourth most common cancer in women worldwide and largely preventable. Almost all cases are caused by persistent infection with high-risk HPV (types 16 and 18 cause about 70%). Bulgaria has one of the higher incidences in Europe.
Pathogenesis
HPV infects the transformation zone (the junction of squamous and columnar epithelium). The viral proteins E6 (inactivates p53) and E7 (inactivates Rb) drive cell proliferation. Most infections clear; persistence leads to cervical intraepithelial neoplasia (CIN) and, over 10–15 years, to invasive cancer.
- Histology: squamous cell carcinoma ≈ 75–80%, adenocarcinoma ≈ 20%.
- Risk factors: early first intercourse, many partners, smoking, immunosuppression (HIV), long-term combined pill use, high parity, no screening.
Clinical picture
- Early disease is often asymptomatic (found by screening).
- Postcoital and intermenstrual bleeding, postmenopausal bleeding, offensive blood-stained discharge.
- Late: pelvic pain, leg oedema, hydronephrosis and renal failure (ureteric obstruction), vesicovaginal or rectovaginal fistula.
- Examination: exophytic or ulcerated lesion, contact bleeding; spread into the parametrium on rectovaginal examination.