IBD and the Risk of Cervical Cancer

Certain drugs used to treat IBD may be connected to cervical dysplasia

People who live with inflammatory bowel disease (IBD), including Crohn’s disease, ulcerative colitis, or indeterminate colitis, may be at a higher risk for having certain other conditions. This includes several types of cancer, including colon cancer, skin cancer, prostate cancer, and cervical cancer.

It’s not clear how the risk of cervical cancer may be increased in women with IBD. It is still an area of study to know if the risk may be higher than it is in healthy women and how that risk is related to medications that suppress the immune system.

Experts disagree, for now, on how much risk could be involved and how large a role medications may play. What is agreed upon is that women with IBD should have regular screening for cervical cancer, probably more often than healthy women do. This article will address the potential causes, risk factors, and preventive measures for cervical cancer in women who live with IBD.

Conducting a Pap test.
Peter Dazeley / The Image Bank / Getty Images 

The Cervix

The cervix is a part of the female reproductive system that’s located at the lower part of the uterus. The cervix is about one-third of the bottom of the uterus and is between the uterus and the vagina. It’s small, about an inch wide and also a bit over an inch long, and it has a small opening in the middle.

The opening in the cervix, through which menstrual blood passes out of the uterus and into the vagina, is called the cervical os. The cervical os opens a bit wider during menstruation. When a woman is pregnant, it closes up until it is time to give birth. During labor the cervix thins out and the cervical os opens up in order to allow the baby to pass out of the uterus and into the vagina.

The cervix plays a role in conception, pregnancy, and childbirth. It produces mucus all the time and even more so when a woman is having her most fertile days (the time when she is most likely to get pregnant).

After conception, the cervix produces a thicker kind of mucus that creates what’s called the mucus plug. The mucus plug covers the cervical os and shields the baby from potential harms, like an infection. The mucus plug thins and is discharged before birth, which is an indication that labor is starting.

The cervix is also subject to a number of diseases and conditions, including cervical cancer. Guidelines call for women to have a screening test called a Pap test or smear at regular intervals in order to check for pre-cancerous cells.

Cervical cancer used to be a leading cause of cancer deaths in women in the U.S. The rate of cervical cancer deaths has decreased in the past few decades, which is thought to be a result of increased screening.

Pap tests are used to screen the cells in the cervix. During a Pap test, a tool called a speculum is used to open the vagina and see the cervix. Cells are taken from the cervix with a wooden or plastic scraper or a cervical brush. These cells are then tested in a laboratory.

If there are abnormal cells found, there may be a need to investigate further and do more tests. An abnormal Pap test result does not automatically mean that cancer is present. In some cases, the abnormal result can be a false positive (meaning that there are no cells of concern present).

Human Papillomavirus

One thing that’s important to understand about cervical cancer is its relationship to the human papillomavirus (HPV). Infection with HPV is common in adults. HPV is transmitted from person to person through sexual contact. It is the most common sexually transmitted virus. Most sexually active adults contract HPV during their lifetime.

In most cases, an infection with HPV will go away on its own and won’t cause any other health issues. However, there are many different strains of HPV. Some strains are associated with more risk of health problems than others are.

The strains that are concerning are those that have been shown to lead to the development of genital warts or to different forms of cancer (such as cervical, vaginal, penile, anal, and throat).

Cervical cancer has been linked to some strains of HPV, including HPV-16 and HPV-18, which are connected to about 70% of cases of cervical cancer.

If a Pap test comes back as “abnormal,” this may mean that there are unexpected types of cells present on the cervix. In some cases, an HPV test is done at the same time as the Pap test. This is called co-testing. If a co-test or an HPV test was not given, it might be used after an abnormal Pap test to see if there are any strains of the virus present.

Immune Suppression

Having IBD, even after having surgery, does not mean that a person is considered to be immunosuppressed. Rather, it is certain types of drugs that are given to treat Crohn’s disease or ulcerative colitis that are causing the immune system to be suppressed.

One way that IBD is managed is through medications that dampen down certain parts of the immune system. These medications have the effect of preventing or stopping the inflammation that goes along with IBD and causes all the damage in the digestive tract and in other parts of the body.

However, having a lowered immune system means that a person may be more likely to develop certain kinds of infections, such as upper respiratory infections. That can also mean infections with HPV.

Receiving immune-suppressing drugs could mean that HPV takes longer to clear from the body. Being clear of HPV for some time and then it showing up on tests later does not always mean that there was a new sexual partner who transmitted it. HPV can lie dormant for years and then show up again on testing after starting immune-suppressing medications. 

Abnormal Pap Test Results and IBD

Women with IBD may have higher returns of abnormal Pap test results than women who do not have IBD. Abnormal cells, which are called cervical dysplasia or cervical neoplasia, could potentially lead to the development of cancer.

A large national cohort study was used to determine the risk of cervical dysplasia and cancer in women with IBD. A cohort study is one in which people who share a characteristic (like having IBD) are followed over a period time.

In the cohort study, women with IBD were matched with control patients who did not have IBD in this study. What the researchers found was that women with and without IBD had about the same screening rates. But more women with IBD, and especially Crohn’s disease, had precancerous cells or cervical cancer than the healthy women did. 

A study from Denmark looked at the risk of several different types of cancer in people diagnosed with Crohn's disease or ulcerative colitis. The rates of cancer in people with IBD were compared with the rates in healthy people who were matched by age and sex. The results showed that women with Crohn's disease were at an increased risk of having abnormal cells on the cervix (cervical dysplasia), which also included early stage cervical cancer (carcinoma in situ or stage 0 cervical cancer.

Researchers acknowledge that it’s not clear yet what could be the cause of abnormal Pap results in some of these studies of women with IBD. Some research seems to indicate that it is related to having IBD, while others show that it may be connected to the use of the immunosuppressive medications that are used to treat IBD. And yet still others didn't find any association with abnormal Pap test results at all.

It's generally agreed, however, that women with IBD should take care to avoid risk factors for cervical cancer, such as smoking. Getting regular screening is also important, along with receiving the HPV vaccine when it is appropriate to do so. While the jury may still be out on what the risk is for women with IBD, the steps to take to prevent cervical cancer remain the same.

Cervical Cancer Screening Intervals in IBD

How often it is recommended that a woman have a Pap test is related to a number of different factors. This includes age, previous history of any abnormal Pap test results, risk of cervical cancer, and having a compromised immune system.

For women with IBD, it is recommended that cervical cancer screening be done more frequently than for healthy women of the same age.

The guidelines for cancer screening indicate that women with IBD who are on medications that suppress the immune system follow the recommendations for immunocompromised persons.

A more IBD-specific recommendation is that women who receive immunomodulators (which include Imuran, 6-Mercaptopurine, and methotrexate) be screened with a Pap test yearly. It is also recommended that women with IBD who are receiving anti-TNF medications (which include Remicade, Humira, Cimzia, or Simponi) also receive yearly screening.

HPV and IBD

A study of women with IBD in China was done to find out how many patients also had infection with HPV. The study especially looked at HPV types 16 and 18. This research also looked into how many of these women with IBD also had changes in the cells of their cervix, including the growth of abnormal cells.

What the researchers found was that women with IBD were more likely to have an infection with HPV-16 or HPV-18 and were also more likely to have cervical dysplasia.

The effect was highest in women who received methotrexate or more than two immunosuppressive drugs. The researchers concluded that women with IBD are at greater risk for infection with HPV for abnormal cervical cells.

The HPV Vaccine

A number of vaccinations are recommended for people who live with IBD before they start therapy with a biologic medication. It has been shown that certain medications for IBD may make people more susceptible to infections.

For that reason, being fully vaccinated as recommended by the IBD team is important before starting these medications. Among others, including influenza and pneumonia vaccinations, the HPV vaccine is also recommended, when it is appropriate.

The HPV vaccine is usually given to children who are 11 or 12 years old. This is because that’s the age when people have the best immune response to the vaccine.

The HPV vaccine can help protect against a number of strains of HPV, including 6, 11, 16, 18, 31, 33, 45, 52, and 58. It’s thought that about 90% of cases of cervical cancer are connected to these strains of HPV.

The HPV vaccine can also be given to girls and women between the ages of 13 and 26 and boys and men between the ages of 13 to 26. Generally speaking, the vaccine is less effective at decreasing the risk of cancer associated with HPV the older a person is when they receive it. In some cases, the vaccine may be given to men and women up to the age of 45.

A Word From Verywell

It’s known that people who live with IBD may be at increased risk for certain types of cancer. When it comes to cervical cancer, there are still some open questions, including how great the risk might be and if certain IBD medications may play a role in increasing risk.

The likelihood of developing cervical cancer will be individualized for every woman with IBD and will depend on age, other conditions, having abnormal Pap results in the past, and medication history.

What is generally agreed upon, however, is that there may be some measure of increased risk and that cervical cancer screening at regular intervals is recommended. In some cases, getting a Pap test might be recommended yearly for women with IBD.

How often testing is needed and at what age it should be started and can be stopped should be a discussion between the patient, a gynecologist, and a gastroenterologist.

For younger women and girls with IBD, the HPV vaccine may be recommended. The vaccine may be effective at preventing infection with many of the HPV strains that are associated with cervical cancer.

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