Tell any woman that her cervical screening test is due and the chance of a positive response is slim. Instead, you’ll likely be met with a groan, a look of panic, or perhaps a look of indifference – after all, one in four women now don’t take advantage of screening, according to the latest figures from NHS Digital.
Every day in the UK, nine women are diagnosed with cervical cancer and three will die from the disease, yet the risk of it developing can be reduced with a simple cervical screening test.
The NHS Cervical Screening Programme invites women aged 25-64 who are registered with a GP to a screening (also known as a smear test) every three to five years, depending on their age. Tracie Miles, information nurse at The Eve Appeal, a charity that raises awareness and funds research into gynaecological cancers, says: “Screening enables early detection of risk factors and cervical changes and failure to attend can significantly increase the risk of developing this potentially preventable cancer.”
She adds: “Screening and vaccination against the high-risk human papilloma virus (HPV – the virus that causes most cervical cancers) in eligible age groups are the two most powerful strategies to protect women from cancer.”
NHS Digital figures show that in the year ending 31 March 2016, 4.2 million women were invited for screening, but only 72.7 per cent attended – the lowest rate for 19 years.
Age had a marked influence on attendance levels. Some 78 per cent of 50-64 year olds attended a screening, compared with just 70.2 per cent of 25-49 year olds. Among women aged 25-29, coverage was significantly lower than in any other age group at 63.3 per cent, meaning that one in three didn’t attend
Tracie puts this partly down to a belief among this age group that “cancer only happens to older people”. However, the fact is that cervical cancer mainly affects sexually active women aged 30-45, so screening from 25 years of age can help to prevent cancer developing later in life. “As healthcare professionals, if we can spot pre-cancerous changes or signs and symptoms that may increase a woman’s risk of developing cancer in the future, for example CIN 1/2/3 or the human papilloma virus, then she won’t become a statistic,” Tracie explains.
A key reason for not attending a screening appointment appears to be a lack of understanding, both about what a cervical screening is for and what the procedure involves. Many women think that cervical screening is a test for cancer, but this is a misconception. “Cervical screening seeks to identify pre-cancerous changes which can be monitored and if any abnormalities are found, [the person] can be treated as an outpatient. However, there is always a sense of fear around the word cancer, so this misconception could be a contributing factor to women not attending their cervical screening,” explains Tracie.
Robert Music, chief executive of Jo’s Cervical Cancer Trust, adds: “People can also be concerned about the result, thinking that if it comes back positive then they have cancer, but that’s not the case.” In fact, the number of positive results returned is relatively small. In 2015/16, 94.5 per cent of adequate screening results came back normal and 4.4 per cent of the remaining test results indicated borderline changes or low-grade abnormalities, which can be treated before cancer develops.
Pain is another concern, explains Robert, saying: “We all have different pain thresholds and it’s more uncomfortable than painful – I know this is coming from a man, but I’m told it’s true! When we speak to women, they’re often surprised about how quick, easy and pain-free it is. It’s that pain perception that we need to break down.”
The letter inviting women to attend a test doesn’t exactly help either. Following recent changes, it now states: “It’s up to you whether or not to have cervical screening”. While factually correct, Tracie believes this phrase might be playing a role in declining rates by suggesting that it’s perfectly acceptable to take the risk and not attend, rather than proactively encouraging women to protect their gynaecological health.
Even with the best of intentions, work and childcare commitments mean that finding a convenient time to attend a screening can be difficult. In a bid to combat this, Jo’s Cervical Cancer Trust launched “Time to Test”, a campaign that encourages employers to allow women time out of their working day to go and get tested if they’re unable to get an appointment outside of working hours. Many big-name companies, as well as some NHS trusts, have already signed up and the charity is encouraging more employers to get involved and take the “Time to Test” pledge.
“Accessibility is another thing we’re shouting about at the minute,” says Robert. “In an ideal world, women could be screened where they want to be. So if a woman lives in Bromley but works in central London, she should be able to go somewhere in central London to have her screening so she could pop in before work or on a lunch break.”
Robert’s other favoured solution to help improve screening rates is the humble text message. “Texting a reminder is the easiest way to improve screening rates,” he claims. “We get them for the dentist now, so why not cervical screening?”
He also makes the point that if people get a letter saying they should ring for an appointment, they’re less likely to do this than if they get a letter saying this is your appointment time. “They’d either go to the appointment or ring to change it, so uptake would increase,” believes Robert.
Cervical cancer in women younger than 25 years of age is rare, but several high-profile cases of younger women dying from the disease have fuelled an ongoing debate about whether the minimum age for screening should be lowered. Robert Music, chief executive at Jo’s Cervical Cancer Trust, says: “It’s very emotive when we see women diagnosed younger than 25, but there’s evidence saying that for women under the age of 25 screening has the potential to do more harm than good.”
Changes in the cervix are quite common in younger women, so screening before the age of 25 could lead to unnecessary treatment and worry, as well as other complications in later life. Robert explains: “Some 99.7 per cent of cervical cancer is caused by HPV and 80 per cent of women have it at some point, but it usually clears up without treatment. If there’s a positive test result, further investigations will take place and these can lead to pre-term labour and harm to the baby if women go on to become pregnant.”
It’s screening for the older age groups that Robert says needs more attention, possibly even extending screening coverage beyond 64 years of age as we’re living longer. “We’re looking at eradicating cervical cancer mortality by 2040 due to the HPV vaccine [which is given to young girls], but at the opposite end, the outlook is not as positive and this is currently under review,” explains Robert.
Opting to go for screening is an individual’s choice. However, with so much misunderstanding about what a cervical screening is for, providing women with the information they need to make an informed choice, as well as offering vital reassurance about the procedure, is important. And this is where pharmacy can help.
Robert says that the most important message to get across to women is that a cervical screening is a five minute test that can literally save lives. “Women are going through hellish treatment because they ignored the letter or put off going for the screening. Some women have lost fertility or even their lives as a result and it can lead to all kinds of other health problems. Cervical cancer is largely preventable and not many other cancers are.” In fact, it is estimated that the NHS screening programme saves around 5,000 lives each year.
Discussing cancer is never easy, even in a healthcare setting like a pharmacy, but links to other health concerns may make the topic easier to broach. For example, Katie Edwards, Cancer Research UK’s health information officer, says: “Talking about giving up smoking could be a good way to introduce the topic of cancer prevention and cervical screening. While most people know smoking is linked to lung cancer, fewer know that it is linked to 13 other types, including cervical cancer.”
Once the topic has been raised, pharmacy staff can answer questions and concerns. “Encouraging people to speak to the practice nurse or GP beforehand could help to make some women feel more comfortable about attending their screening appointment,” suggests Katie. “They can ask about what will happen during the appointment and discuss any ways in which they could be made to feel more comfortable.”
Tracie adds that pharmacy staff can find out information and download resources about cervical cancer to display in the pharmacy or pass on to customers from charity websites such as Jo’s Cervical Cancer Trust.
Most cervical cancer cases are caused by the human papilloma virus (HPV), and in 2008, immunisation against HPV was introduced in the UK for girls aged 12 and 13. A catch-up campaign started in 2009 to vaccinate all girls up to 18 years of age. These women are now eligible for cervical screening and Robert explains that initial data look very positive: “Abnormalities are decreasing due to the vaccine and long term the outlook is even better. If coverage of the vaccine was at 80 per cent year on year, by 2025 there would be a one-third reduction of incidence of cervical cancer in women under 30. At the minute, coverage is high at 86 per cent, so this could be even better.”
Despite this positivity, Katie cautions: “Cervical screening is still important for girls who have been given the HPV vaccination as there are many types of HPV linked to cervical cancer, and the vaccine does not protect against all of them.” She also says it’s important to remember that cervical screening is for women without symptoms and adds: “Whatever their age, any woman experiencing unusual or persistent bleeding, pain, or a change in vaginal discharge – even if they’ve been screened recently or have a screening invitation – should get it checked out by their GP straight away. Chances are it won’t be cancer, but if it is, getting it diagnosed and treated early can make a real difference.”
One in three women experience bladder weakness at some point in their lives. It can occur at any age, but is more prevalent once the pelvic muscles are damaged or weakened, for example during pregnancy. The condition can be controlled with lifestyle measures, such as losing weight, drinking plenty of fluids, cutting down on caffeine and alcohol and doing pelvic floor exercises to strengthen the muscles. Pharmacy staff can also direct customers to the range of bladder weakness protection products available.
Cystitis is an inflammation of the bladder, usually caused by bacteria entering the urethra from outside and infecting the bladder. The main symptom is an intense pain and/or burning sensation when passing urine. Other symptoms include increased frequency of urination, passing small quantities of urine, and cloudy, foul smelling urine. Customers should be advised to drink plenty of fluids to flush out the bladder, take painkillers if necessary, and always wipe front to back when going to the toilet. OTC treatments containing potassium or sodium citrate may also help.
Thrush and bacterial vaginosis
Thrush is a yeast infection caused by Candida albicans. Symptoms include itching and soreness around the vagina and a white cottage cheese-like vaginal discharge. Hormonal changes, wearing tight or synthetic clothing or taking antibiotics can all trigger an infection, which can be treated with an OTC antifungal cream, tablet or pessary.
Bacterial vaginosis (BV) is caused by an overgrowth of bacteria in the vagina and is characterised by a white/grey, thin and watery discharge, and a noticeable fishy odour. OTC products that restore the pH balance of the vagina can be recommended.
Pregnant women with suspected BV or thrush should be referred to the pharmacist.
Morning after pill
A woman who has had unprotected sex or who thinks her contraception may have failed may want to use emergency hormonal contraception (EHC), also known as the morning after pill. There are two oral emergency hormonal contraceptives available over the counter in pharmacy – levonorgestrel and ulipristal acetate – which can be taken up to three and five days respectively after unprotected sex. Both pills work by preventing or delaying ovulation, and the sooner they are taken, the more effective they will be at preventing pregnancy. A pharmacist must be directly involved in all sales of EHC.
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When we speak to women, they’re often surprised about how quick, easy and pain-free it is