Introduction

Cervical cancer is the fourth most common cancer affecting people assigned female at birth (AFAB) worldwide.¹ While the main focus of cervical cancer is typically disease prevention and treatment, the impact of cervical cancer on mental health should not be ignored. Patients diagnosed with cervical cancer can experience various mental health challenges, ranging from the emotional impact of the diagnosis to low self-esteem, strained relationships and intimacy concerns.

Let’s explore cervical cancer and its effects on mental health.

Understanding cervical cancer

The cervix is the part of the female reproductive system that connects the vagina to the uterus. Anyone with a cervix can potentially develop cervical cancer. Risk factors for cervical cancer are deemed to be any factors that can increase your chances of developing the disease. Having one or several risk factors does not mean that you will develop cervical cancer, but it will increase your chances of developing it. 

Modifiable risk factors

There are several risk factors that you can change (i.e. are modifiable):

Infection with human papillomavirus (HPV)

• Human papillomavirus (HPV) is well-recognised as the risk factor for cervical cancer²
• HPV is transmitted through sexual or skin-to-skin contact
• It can cause skin lesions known as papillomas or genital warts 
• You can help protect yourself against HPV infection by using condoms. The HPV vaccine also reduces the risk of getting HPV and cervical cancer

Sexual history

• Aspects of your sexual history can increase your risk of developing cervical cancer. These include:
  • Early onset of sexual activity (before the age of 18)³
  • Having many sexual partners and/or having a partner who is considered a high-risk person (i.e. they have HPV or have had many sexual partners)⁴

Smoking

• Active and passive smokers are exposed to many harmful chemicals that not only affect the lungs but can also affect other organs, including the uterus (womb) 
• Tobacco by-products weaken the immune system and cause damage to the DNA of cervical cells which may contribute to cervical cancer development⁵

A weak immune system

• A strong immune system is important in recognising and destroying individual cancer cells as they develop, thereby preventing their growth and spread 
• People AFAB with weak immune systems are at an increased risk of developing cervical cancer as they cannot fight infections like HPV effectively. This includes people AFAB who are living with HIV/AIDS or who take immunosuppressant drugs 

Infection with chlamydia

• Chlamydia is a sexually transmitted infection that commonly does not cause symptoms in people AFAB 
• It can cause pelvic inflammation, which can lead to infertility
• Research has shown that chlamydia infection is an important risk factor for cervical cancer⁶
• It has also been suggested that people AFAB with a current or past history of chlamydial infection may need further screening as they have a high risk of developing the disease⁶

Long-term use of oral contraceptives

• Long-term use of oral contraceptives (also known as birth control pills) is associated with an elevated risk of cervical cancer
  • One study found a 10% increased risk for less than 5 years of use, a 60% increased risk with 5-9 years, and a doubling of the risk with 10 or more years of use⁷
  • However, it is also worth noting that cervical cancer risk has been found to decline over time after stopping the use of oral contraceptives⁸

Having multiple full-term pregnancies

• Having more than five full-term pregnancies (also known as ‘high parity’) is associated with an increased risk of cervical cancer⁹
  • This risk is believed to be due to greater exposure to HPV during sexual activity. During pregnancy, the immune system weakens which can increase susceptibility to HPV infection and the development of cervical cancer

Young age at first full-term pregnancy

• Studies have found cervical cancer risk to be higher in people AFAB who had their first full-term pregnancies under 17 years old, compared to those who had their first full-term pregnancies at age 25 or older¹⁰

Low economic status

• People AFAB of low economic status have an increased risk of cervical cancer¹¹
• This is believed to reflect challenges in accessing health care and screening services for HPV and cervical cancer

A diet low in fruit and vegetables

• Diet plays an integral role in our overall health
  • Fruits and vegetables contain antioxidants that strengthen our immune system and help fight HPV infection 
  • A diet lacking in fruits and vegetables may therefore increase the risk of developing cervical cancer over the long term

Non-modifiable risk factors 

The following risk factors cannot be changed:

Having a family history of cervical cancer 

• Genetics plays a key role in cervical cancer risk
  • Having a mother or sister who has had cervical cancer may increase your chance of developing it too¹²

Diethylstilbestrol (DES)

• Between 1938 and 1971, some pregnant people were given diethylstilbestrol (DES) to prevent miscarriage
  • It was later found that the children of those who were given DES had a higher risk of developing vaginal and cervical cancer

Early detection and screening methods 

It is difficult to detect cervical cancer early as it does not usually cause any symptoms during its early stages.

However, symptoms of cervical cancer can include:

• Vaginal bleeding after sex
• Vaginal bleeding after menopause
• Irregular vaginal bleeding in between periods
• Abdominal pain and back pain 
• Pelvic pain or pain during sexual intercourse
• Vaginal discharge that contains blood or has a bad odour

Successful treatment of cervical cancer involves early detection. Regular cervical screening is key to identifying cervical cancer early.

Cervical screening 

During cervical screening (formerly known as a smear test), a sample of cells is taken from your cervix to check the health of the cervix. The sample is examined under a microscope to look for the presence of high-risk types of HPV that can cause changes to the cells of your cervix. If such types are found, the sample is then examined for any changes in the cells of the cervix. 

If the screening finds changes to the cervical cells, a cervical colposcopy will be carried out. This is a test in which a healthcare professional looks closely at the cervix using a microscope.

Treatment options

The treatment that a patient receives for cervical cancer depends on the type and stage of the cancer as well as their overall health.

Hysterectomy 

• A hysterectomy is a type of surgical procedure to remove the womb.
  • A simple hysterectomy involves the removal of the cervix, womb, and fallopian tubes while leaving the ovaries 
  • If cancer spreads to surrounding organs, the surgeons will have to remove additional anatomical structures to the womb and cervix – the ovaries, fallopian tubes, and nearby lymph nodes. This is called radical hysterectomy

Chemotherapy 

• Chemotherapy involves the administration of anti-cancer drugs to destroy cancer cells 
• It can be used alone or in combination with other types of treatment

Radiotherapy 

• Radiotherapy involves using high-energy X-rays to kill cancer cells in a targeted way
• It can also be used alone or in combination with chemotherapy and/or surgery

Targeted therapy

• Targeted therapy (such as bevacizumab) is a type of precision medicine, where proteins that control cancer cell growth, division, and spread are targeted

Immunotherapy

• Immunotherapy (such as pembrolizumab) involves harnessing the patient’s own immune system to fight cancer

Mental health challenges 

A cancer diagnosis can be overwhelming for the person receiving it and also for their loved ones. After receiving a cancer diagnosis, a person can experience a variety of emotions, as is natural when facing a life-threatening disease. 

Let's look into some of the major mental health challenges associated with cervical cancer.

Anxiety and depression

• Patients diagnosed with cervical cancer can become vulnerable to developing mental health challenges. Studies have shown that symptoms of anxiety and depression are relatively high among patients with cervical cancer¹³

Body image issues and self-esteem

• Cervical cancer treatment can greatly affect a patient’s body image 
• Surgery involving the removal of reproductive parts or any additional organs as well as the side effects of chemotherapy and radiation can lead to significant changes in weight, physical appearance, as well as sexuality 
• Some patients may experience feelings of ‘diminished femininity’ which can negatively impact their self-esteem 

Sexuality and intimacy concerns

• Cervical cancer and its treatment can immensely affect a patient’s sexuality and the longing to be desired by their partner 
• Vaginal dryness, decreased libido, or reduced fertility are some of these cervical cancer symptoms and treatment side effects

Social isolation 

• Going through lots of emotions and experiencing low energy can cause some patients to feel the need to isolate themselves 
• Cervical cancer patients may also lack the energy and motivation to maintain social activities

Coping strategies and support 

Cervical cancer treatment should involve treating a person as a whole. This means mental health and psychological support should be acknowledged.

Patient education and self-care practice

• A cancer diagnosis is very overwhelming and can be difficult to accept 
• Patients should be advised to understand the disease, how it occurs, and how it can be treated as misunderstandings may lead to the refusal of treatment 
• Being empowered with knowledge about cancer patients enables patients to make well-informed decisions about their wellbeing

Support networks and expression of feelings

• Getting support from family, friends, loved ones and healthcare providers can be beneficial 
• Joining support groups through social media or in person offers the opportunity to share one's personal story, learn coping strategies and feel less alone which patients can find empowering

Seeking professional support

• Coping with a diagnosis of cervical cancer is challenging and can feel overwhelming. Do not hesitate to seek professional support if you feel the need to 
• Healthcare professionals, including your GP and clinical nurse specialist, can offer support or an onward referral if needed 
• Medications including antidepressants, anti-anxiety medications can be prescribed if needed 

Summary

• Cervical cancer is the fourth most common cancer affecting people AFAB worldwide 
• A cervical cancer diagnosis can be devastating as it affects parts of the female reproductive system and therefore can affect a patient’s feelings of femininity and self-esteem 
• Patients diagnosed with cervical cancer may experience mental health challenges including anxiety and depression, issues with body image and self-esteem, sexuality and intimacy concerns, and social isolation
• Cervical cancer patients should be treated holistically, with any mental health challenges being addressed alongside the management of the disease itself 
• Knowledge of cervical cancer, its causes, and treatments can help patients make informed decisions on their condition 
• Patients can find it beneficial to seek support from friends, family, and communities both during and after their treatment
• Healthcare professionals and support groups are also able to provide support and guidance and patients should not hesitate to get in contact with them if they feel the need