Diagnosis of cervical cancer: examinations when cancer is suspected

Notice: Information from the Internet can give you an overview. However, they are not intended to be a substitute for consultation with a health care professional.

Contact person in case of symptoms

For many women, the gynecologist is the first port of call for symptoms such as bleeding or discharge. You can also contact your family doctors. For further examinations, these doctors refer patients to other specialists or to a clinic.

If the suspicion of cervical cancer is confirmed? Then doctors at a specialized center should make a final assessment of the findings. Because they have a lot of experience with the disease. Once diagnosed, affected women can also be treated in such a center.

There are certified centers for the treatment of tumors of the female reproductive organs, including cervical cancer. Those affected can search for such a center on the OncoMAP website by entering "gynecology" in the search mask Select.

The doctors who performed the initial examinations can also help you choose the right clinic. Women who already have or have had cervical cancer can also provide useful information based on their experience. Support groups and patient organizations can help make the connection.

Physical examination, smear test and tissue sample

In the gynecologist’s office, the doctor first finds out about the patient’s health and asks what complaints the patient has. All women are then examined by a gynecologist.

A speculum is a tube-shaped instrument used in gynecological examinationsWith the help of a so-called speculum gynecologists examine their patients. © Praisaeng, Shutterstock

This is how the examination works: Women must first undress underneath and sit in the examination chair. Then the doctor palpates the cervix, cervix, uterus and ovaries through the vagina and abdominal wall. They can also palpate any cancerous tumors via the rectum.

To get a better view of the tissue, they insert a tube-shaped instrument called a speculum into the vagina. The doctor can take a cell smear from the cervix, which is then examined under the microscope.

Colposcopy, biopsy or conization

Gynecologist during a colposcopic examinationDuring a colposcopy, the gynecologist looks through a special microscope at the tissue on the cervix. © Try_my_best, Shutterstock

If the tissue on the cervix cannot be adequately assessed with the naked eye, the doctors examine it with a special microscope, the so-called colposcope. This examination is called a vaginal endoscopy or colposcopy.

If the doctors discover conspicuous areas of tissue, they take a tissue sample. Specialists examine this sample under a microscope for cell changes. Read more about this under Biopsy.

Colposcopy: Examination of the vagina and cervix using a microscope.
biopsy: Taking a tissue sample
Conization: Cutting out a cone-shaped piece of tissue from the cervix and cervix

Small, well-defined change: If the tissue change is small and can be easily distinguished from the surrounding healthy tissue, the doctors may remove it completely. Specialists speak of a conization. They cut out a small cone from the cervix: the diseased tissue and, for safety, a seam of healthy tissue.

How stressful is the examination?

The gynecological examination is unpleasant for many women, but it does not usually hurt. A biopsy of the cervix is also usually hardly painful.

However, if there is a more serious disease, it can be different. Then local anesthesia is possible, which relieves the pain. In the case of very severe discomfort, doctors can also induce a short anesthetic, but this is not feasible in every gynecologist’s office.

Important to know: If the tissue removal takes place on an outpatient basis under anesthesia, women should be picked up afterwards and should not drive themselves, for example.

What happens next?

The cell smear or tissue sample is examined for cancer cells under the microscope.

If the result of the examination is a precancerous lesion on the cervix? To find out what happens next for affected women, read the text Pre-cancerous stages of the cervix: examination and treatment.

If the suspected cancer is confirmed? This is followed by further examinations, for example imaging procedures and surgery for final staging. You can find out more about these examinations in the next sections.

Read more

Imaging procedures

Once the diagnosis of cancer is confirmed, patients undergo further examinations. With imaging techniques, doctors primarily examine how far the tumor has spread in the area around the cervix and in more distant organs.


Doctor holds ultrasound probe on the abdomen of a lying womanDoctors can use an ultrasound through the abdominal wall to determine whether the kidneys and urinary tract are affected by cancer. © Khakimullin Aleksandr, Shutterstock

To determine how far the tumor has already spread, the gynecologist will perform ultrasound examinations:

Vaginal ultrasound: All patients receive an ultrasound through the vagina. This allows doctors to see if the tumor has spread to other tissues and organs in the area besides the cervix.

Ultrasound through the abdominal wall: In all affected women, doctors perform an ultrasound of the outside of the abdomen. They examine whether the kidneys or urinary tract are affected and therefore the urine does not flow normally.

Ultrasound of the cervical lymph nodes: In some patients, the doctors also examine the lymph nodes in the neck area with an external ultrasound. This allows them to detect lymph node metastases.

This is how the examination works: During a vaginal ultrasound, the gynecologist inserts a rod-shaped ultrasound probe into the vagina. If an abdominal or cervical ultrasound is performed, she or he will place an ultrasound probe on the abdominal wall or in the cervical area. This is how doctors obtain ultrasound images from the region they want to examine and can evaluate them. An ultrasound examination is usually painless and does not involve radiation exposure.

Magnetic resonance imaging (MRI)

If the tumor has already spread further, doctors also use magnetic resonance imaging (MRI) to examine its spread in the pelvis. The device uses strong magnetic fields to generate images from inside the body. This enables doctors to assess how deeply the tumor has grown into the tissue, whether and which neighboring organs in the pelvis are affected, and whether any lymph nodes are involved.

However, doctors can only perform an MRI on patients who do not have metal in their bodies. These include, for example, implants and pacemakers. If an MRI is not possible, doctors instead extend computed tomography to the pelvic area.

Here’s how the exam works: For the MRI, the patient lies down on a couch that travels through a tube-shaped device. The examination is painless. There is no radiation exposure. If sufferers are afraid of confined spaces, then they can be given a sedative before the MRI. However, they are not allowed to drive a car or ride a bicycle after the examination and should be picked up.

Computed tomography (CT)

If the tumor has already spread further, women also receive computed tomography (CT) scans of the chest and abdomen. In patients for whom MRI is not possible, doctors also use CT to examine the pelvic area. The device generates images of the inside of the body by means of X-rays. Doctors use it to check whether metastases are present, for example in the lungs.

Only a few patients need positron emission tomography (PET) in combination with CT (PET-CT). Doctors use it mainly in women with a relapse to find possible metastases.

  • Important: The costs for a PET-CT are not automatically covered by the statutory health insurances.

This is how the examination works: For a PET-CT, the doctor first injects a contrast medium into the vein. The patient lies down on an examination table for the CT scan, which passes through a ring-shaped opening. The examination is painless. It involves some exposure to radiation. However, experts consider the health risk acceptable if the examination is necessary.

Surgery for staging

Two doctors operateWith surgery, doctors can more accurately assess the spread of the tumor. © I AM NIKOM, Shutterstock

In many patients, doctors perform surgery to more accurately assess how far the tumor has spread. Experts speak of surgical staging. Only in patients with very early cervical cancer is this procedure not necessary. Normally, the procedure is performed as a laparoscopy, or abdominal endoscopy.

Important to know: Depending on the results of the laparoscopy, surgical staging may progress to actual treatment: If the doctors can already decide during the examination which treatment makes sense, then they remove the uterus right away, for example.

This is how the examination works: The patient receives anesthesia for the procedure. The doctor inserts instruments and cameras through small incisions in the abdominal wall. This allows them to examine organs and tissues in the pelvis and lower abdomen.

In addition, they take tissue samples and lymph nodes in the vicinity of the tumor. Whether all lymph nodes are removed or only so-called sentinel lymph nodes close to the tumor depends on the stage of the tumor. The samples taken are examined by specialists in the laboratory for cancer cells.

In pre-menopausal patients, the doctors also relocate the ovaries during the operation. If radiation therapy takes place later, then they are better protected from possible radiation consequences.

What side effects may occur? Surgical staging is not an extensive procedure. Patients face the usual risks of anesthesia. There may be problems with wound healing. If the doctors remove many lymph nodes, lymphedema can develop in the legs. It is also possible that nerves may be inj.

Tumor marker

Tumor markers usually play no role in diagnosing cervical cancer: they have been shown to be too inaccurate. Some doctors still determine tumor markers. If they were determined during the initial diagnosis, then doctors can compare the values during follow-up care.

The following tumor markers may be elevated in cervical cancer:

  • SSCA (squamous cell carcinoma antigen) in squamous cell carcinoma
  • CEA (carcinoembryonic antigen) and CA 125 (cancer antigen 125) in adenocarcinoma
  • NSE (neuron-specific enolase) in a neuroendocrine tumor

Staging of cervical cancer

For treatment planning, it is particularly important to know how far the cancer has progressed. This is what doctors describe with the help of disease stages. For cervical cancer, there are several systems to determine the stage of disease.

TNM classification: In this staging, different categories describe how far the tumor has spread:

  • T: How large and how extensive is the actual tumor (T0 to T4)?
  • N: If lymph nodes near the tumor are affected (N0 or N1, Latin Nodus = node)?
  • M: Are there already metastases, i.e. tumor metastases in other organs or tissues (M0 or M1)?

Example: T1N0M0 is a small tumor that has not yet affected any lymph nodes and has not metastasized. If there is an "X" instead of a number behind the T or N indications, this means that the doctors cannot (yet) assess the situation.

FIGO classification: For gynecological tumors, gynecologists have also developed the so-called FIGO classification. It is named by the International Federation of Gynecology and Obstetrics. The FIGO classification is largely consistent with the TNM classification.

In stage 1, the tumor is confined to the cervix; in stage 2, it grows beyond it; in stage 3, the tumor grows to the pelvic wall or into the lower third of the vagina; in stage 4, it grows into the abdomen or forms distant metastases Doctors use stage of disease to describe how far cervical cancer has spread. © Cancer Information Service, DKFZ, created with BioRender.com

Doctors group the TNM indications into disease stages. The stages of cervical cancer are described with Roman numerals and letters:

  • 0 ("stage zero"): Early stage cancer – the tumor grows only in the upper tissue layers of the cervix. Experts also speak of a carcinoma in situ. Stage 0 corresponds to high-grade squamous cell dysplasia (CINIII).
  • I ("stage one"): The tumor is limited to the cervix.
    IA ("Stage One A"): The tumor is so small that it can only be seen under a microscope. Experts also refer to this as microinvasive carcinoma.
    IB ("stage one B"): The tumor is somewhat larger, so that it is visible to the naked eye. Specialists speak of a macroinvasive carcinoma. Doctors also classify a tumor that can only be seen microscopically and has penetrated deeper than 5 millimeters here.
  • II ("stage two"): The tumor has spread beyond the uterus, but has not reached the pelvic wall or the lower third of the vagina.
    IIA ("stage two A"): The tumor grows in the upper third of the vagina, but the supporting apparatus of the uterus (parametria) is still free of tumor.
    IIB ("stage two B"): The supporting apparatus of the uterus is affected.
  • III ("stage three"): The tumor has spread to the pelvic wall and/or involved the lower third of the vagina and/or is affecting kidney function.
    IIIA ("stage three A"): The lower third of the vagina is affected, but the pelvic wall is free.
    IIIB ("stage three B"): The tumor has spread to the pelvic wall or is causing renal congestion. In addition, lymph nodes may be affected. Doctors also classify smaller tumors with lymph node involvement in this stage.
  • IVA ("stage four A"): The tumor has grown into the mucosa of the bladder or rectum or is growing into the abdomen.
    IVB ("stage four B"): Tumor metastases have formed in distant organs (distant metastases).

In stage one, the tumor is confined to the cervix; in stage two, it grows beyond it; in stage three, the tumor grows to the pelvic wall or into the lower third of the vagina; in stage four, it grows into the abdomen or forms distant metastases

Grading: How malignant is the tumor??

In addition to the spread of the tumor, experts determine the so-called degree of differentiation on the tissue: it indicates how much the cancer cells differ from normal tissue. The classification ranges from G1 (well matured, largely normal tissue) to G3 (undifferentiated tissue). The more the tumor differs from normal tissue, the more malignant it is.

Sources and links for interested parties and specialists

You have questions about cervical cancer? We are here for you.

How to reach us:

  • on the phone free of charge at 0800 – 420 30 40, daily from 8 a.m. to 8 p.m
  • by mail to [email protected] (data secure contact form)

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They professionally care for patients with cervical cancer and have questions about how to? cancer information service.med will assist you with your research and arrange for informational materials. The service is available Monday through Friday:

  • by telephone from 8 a.m. to 8 p.m. at 0800 – 430 40 50
  • by email to [email protected] (data secure contact form)

Sources and further information

Tumor Classification

Wittekind CH. TNM classification of malignant tumors. Wiley-VCH, 8. Edition 2017

Horn LC, Brambs CE, Opitz S, Ulrich UA, Hohn AK. FIGO classification for cervical cancer 2019 – what’s new?. Pathologist 2019. 40, 629-635 https://doi.org/10.1007/s00292-019-00675-w

For more information on the sources used to create the text, as well as useful links, see the overview on cervical cancer.

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