Patients present with four stages of disease:

  • Asymptomatic, pre-invasive or early invasive disease that is detected on pap-smear. This is the most common presentation in developed countries with an established screening program.
  • Symptoms due to early invasive disease (usually bleeding outside of normal menstrual cycles)
  • Symptoms due to locally advanced disease (usually more extensive bleeding, malodourous discharge, pain due to pelvic spread or occlusion of endocervical canal)
  • Symptoms due to metastatic disease (weight loss, fatigue, symptoms related to metastatic sites). This is uncommon without pelvic symptoms.


History of Presenting Problem

In some cases there may be no presenting problem other than a positive Pap test. Symptoms to enquire about include:

  • Bleeding: Length of symptoms, frequency, associated factors (intercourse, relation to menstrual cycle)
  • Pain: Length of symptoms, severity, associated factors (intercourse, relation to menstrual cycle), character
  • Vaginal discharge (other than blood)
  • Signs of systemic disease (weight loss, loss of appetite, bone pains)

Related Risk Factors

Important risk factors should be enquired about, including:

  • Smoking history
  • Sexual history (number of partners, age of first intercourse, monogamous relationships etc)
  • O&G history (pregnancies, miscarriages, future plans, previous treatment for gynaecological issues, use of OCP or HRT)
  • Immunosuppression (transplant, HIV/AIDS etc)

Past History

Aside from inquiring about illnesses that lead to immunosuppression (see above), patients should also be asked about previous radiotherapy treatment and other general health questions to establish their fitness for further treatment.


A full list should be taken, paying special attention to:

  • Immunosuppressive drugs
  • Anti-coagulants (warfarin, clopidogrel)
  • Radiation enhancers (methotrexate)


Nil specific

Family History


Pap Test

The Pap test or smear is the test from which cervical cancer screening has become possible. The test is named for Dr Georgios Papanikolaou, who invented the test.

The procedure of the Pap test involves:

  • Obtaining informed consent from the patient (or guardian in patients unable to give consent)
  • Ask the patient to remove clothing from below the waist
  • Position the patient supine on a bed
    • Preferably the bed should have stirrups and no lower half to facilitate introduction of the speculum into the vagina
    • When a bed like this is not available, the patient's pelvis should be supported on pillows to elevate it from the bed
  • The patient should bend bend their knees to 90o, place the soles of their feet together and separate their legs
  • A warmed speculum should be used
  • Lubricant is not recommended; it may be used in some cases so long as it does not become applied the cervix.
  • The speculum is inserted and opened so that the cervix is visible

Helpful Links

The NCI Bethesda Atlas has cytology images for the different findings of Pap tests.

Examination Under Anaesthesia

Examination under anaesthesia is an essential component of clinical staging. It allows determination of tumour size, invasion of vagina and invasion of the parametrium or adjacent organs.


PET staging, although not included in FIGO staging, allows detection of clinically occult metastatic disease. This is able to guide the treatment plan.